1790213064 NPI number — PEBBLE CREEK MEDICAL GROUP PLLC

Table of content: (NPI 1790213064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790213064 NPI number — PEBBLE CREEK MEDICAL GROUP PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEBBLE CREEK MEDICAL GROUP PLLC
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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790213064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18210 N ORGAN PIPE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUN CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85373-1757
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-410-6951
Provider Business Mailing Address Fax Number:
480-304-3234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 N ESTRELLA PKWY # 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOODYEAR
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85338-9271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-322-2144
Provider Business Practice Location Address Fax Number:
623-322-1165
Provider Enumeration Date:
05/31/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BOMMAKANTI
Authorized Official First Name:
SANJAY
Authorized Official Middle Name:
Authorized Official Title or Position:
MD/OWNER
Authorized Official Telephone Number:
623-337-6897

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  37252 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 281108 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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