MEDICARE: SUNDANCE MEDICAL ASSOCIATES PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	AZ3872	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942481718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNDANCE MEDICAL ASSOCIATES PLLC

Provider Business Mailing Address
First Line	:	633 E RAY RD STE 133
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85296-4206
Country	:	US
Telephone Number	:	480-782-0609
Fax Number	:	480-782-0610

Provider Business Practice Location Address
First Line	:	633 E RAY RD STE 133
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85296-4206
Country	:	US
Telephone Number	:	480-782-0609
Fax Number	:	480-782-0610

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SEAN K SACKETT
Credential	:	D.O.
Telephone Number	:	480-782-0609

Provider Enumeration Date	:	11/20/2007
Last Update Date	:	11/28/2012

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