Provider Demographics
NPI:1588903686
Name:ARIZONA MEDICAL GROUP LLC
Entity type:Organization
Organization Name:ARIZONA MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ARUN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKSHMIPATHY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-920-3318
Mailing Address - Street 1:4531 N 16TH ST STE 114
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5344
Mailing Address - Country:US
Mailing Address - Phone:602-920-3318
Mailing Address - Fax:602-926-8937
Practice Address - Street 1:14505 W GRANITE VALLEY DR
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5795
Practice Address - Country:US
Practice Address - Phone:602-920-3318
Practice Address - Fax:602-926-8937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-08
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33461207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ793185Medicaid
AZ793185Medicaid