Healthcare Provider Details

I. General information

NPI: 1801189519
Provider Name (Legal Business Name): SRP FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2011
Last Update Date: 05/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 N 2ND ST SUITE 200
PHOENIX AZ
85012-2368
US

IV. Provider business mailing address

PO BOX 36395
PHOENIX AZ
85013-9998
US

V. Phone/Fax

Practice location:
  • Phone: 602-889-9880
  • Fax:
Mailing address:
  • Phone: 602-889-9880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. SANJAY R PATEL
Title or Position: MEDICAL DIRECTOR/OWNER
Credential: MD
Phone: 602-889-9880