=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902788185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUHRUD JAYADEV PANCHAWAGH MBBS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2025
-----------------------------------------------------
Last Update Date | 07/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13400 E SHEA BLVD
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85259-5499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-301-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2311 E UNION HILLS DR APT 221
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85024-3046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-570-2718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | R81786
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------