Provider Demographics
NPI:1982005328
Name:SUN ARIZONA MEDICAL GROUP P.C.
Entity type:Organization
Organization Name:SUN ARIZONA MEDICAL GROUP P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-372-5081
Mailing Address - Street 1:13943 N 91ST AVE STE A102
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-3688
Mailing Address - Country:US
Mailing Address - Phone:480-372-5081
Mailing Address - Fax:480-398-7618
Practice Address - Street 1:13943 N 91ST AVE STE A102
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-3688
Practice Address - Country:US
Practice Address - Phone:480-372-5081
Practice Address - Fax:480-398-7618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3323482OtherCIGNA/GREAT WEST
AZ944482OtherAHCCCS/MEDICAID
AZZ171015OtherMEDICARE PTAN