1780155077 NPI number — PB MEDICAL GROUP OF ARIZONA, LLC

Table of content: (NPI 1780155077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780155077 NPI number — PB MEDICAL GROUP OF ARIZONA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PB MEDICAL GROUP OF ARIZONA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780155077
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7444 LONG AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SKOKIE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60077-3214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-329-4100
Provider Business Mailing Address Fax Number:
847-329-4900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 N 91ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85037-4037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-840-2588
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/11/2018

Additional Information

Authorized Official

Authorized Official Last Name:
KUCHINSKAS
Authorized Official First Name:
ALICE
Authorized Official Middle Name:
Authorized Official Title or Position:
VP PAYER RELATIONS & OPERATIONS
Authorized Official Telephone Number:
562-303-9741

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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