Healthcare Provider Details

I. General information

NPI: 1740610039
Provider Name (Legal Business Name): ATLANTIS MEDICAL GROUP AZ PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2013
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 N 19TH AVE
PHOENIX AZ
85015-2450
US

IV. Provider business mailing address

5501 N 19TH AVE STE 103
PHOENIX AZ
85015-2451
US

V. Phone/Fax

Practice location:
  • Phone: 602-589-0500
  • Fax: 602-314-4552
Mailing address:
  • Phone: 602-802-8636
  • Fax: 602-314-4552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: SEAN RENEAU
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 602-802-8636