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General NPI Number Information
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NPI Number | 1790213064
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Entity Type | Organization
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Legal Business Name | PEBBLE CREEK MEDICAL GROUP PLLC
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Dates
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Enumeration Date | 05/31/2017
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Last Update Date | 05/31/2017
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Provider Practice Location Address
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Address Line | 700 N ESTRELLA PKWY # 130
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City | GOODYEAR
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State | AZ
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Zip | 85338-9271
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Country | US
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Telephone | 623-322-2144
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Fax | 623-322-1165
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Provider Business Mailing Address
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Address Line | 18210 N ORGAN PIPE DR
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City | SUN CITY
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State | AZ
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Zip | 85373-1757
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Country | US
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Telephone | 602-410-6951
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Fax | 480-304-3234
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Authorized Official
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Title or Position | MD/OWNER
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Name | SANJAY BOMMAKANTI
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Credential | MD
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Telephone | 623-337-6897
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 37252
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License Number State | AZ
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