Healthcare Provider Details

I. General information

NPI: 1104133446
Provider Name (Legal Business Name): POLARIS MANAGEMENT GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 09/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 E 2ND ST SUITE 106
SCOTTSDALE AZ
85251-5600
US

IV. Provider business mailing address

PO BOX 1598
SCOTTSDALE AZ
85252-1598
US

V. Phone/Fax

Practice location:
  • Phone: 858-699-0572
  • Fax:
Mailing address:
  • Phone: 858-699-0572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number42765
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number42765
License Number StateAZ

VIII. Authorized Official

Name: DR. SONJA WANEBO
Title or Position: MANAGER
Credential: MD
Phone: 858-699-0572