Healthcare Provider Details

I. General information

NPI: 1265696124
Provider Name (Legal Business Name): ARIZONA WELLNESS ANESTHESIA GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6005 S 36TH ST
PHOENIX AZ
85042-4901
US

IV. Provider business mailing address

6005 S 36TH ST
PHOENIX AZ
85042-4901
US

V. Phone/Fax

Practice location:
  • Phone: 602-595-5145
  • Fax: 602-595-5302
Mailing address:
  • Phone: 602-595-5145
  • Fax: 602-595-5302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number37002
License Number StateAZ

VIII. Authorized Official

Name: IGOR KRAVCHENKO
Title or Position: OWNER
Credential: MD
Phone: 602-595-5145