Provider Demographics
NPI:1194609420
Name:PHYSICIAN PAY GROUP LLC
Entity type:Organization
Organization Name:PHYSICIAN PAY GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALI-ANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:OTTUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-321-6627
Mailing Address - Street 1:4241 N 23RD AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-7006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9002 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2405
Practice Address - Country:US
Practice Address - Phone:480-321-6627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-31
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Multi-Specialty
No163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Multi-Specialty
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & AdolescentGroup - Multi-Specialty
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Multi-Specialty
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No364SP0810XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & FamilyGroup - Multi-Specialty
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty