Healthcare Provider Details

I. General information

NPI: 1518137520
Provider Name (Legal Business Name): PHYSICIAN GROUP OF ARIZONA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 E WASHINGTON ST SUITE 200
PHOENIX AZ
85034-2004
US

IV. Provider business mailing address

PO BOX 281201
ATLANTA GA
30384-1201
US

V. Phone/Fax

Practice location:
  • Phone: 602-507-4500
  • Fax: 602-688-8311
Mailing address:
  • Phone: 866-243-7104
  • Fax: 314-432-9683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY KOCH
Title or Position: CFO
Credential:
Phone: 617-562-7070