Provider Demographics
NPI:1083735799
Name:PROGRESSIVE HEALTHCARE GROUP INC
Entity Type:Organization
Organization Name:PROGRESSIVE HEALTHCARE GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-586-9111
Mailing Address - Street 1:PO BOX 1819
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85602-1819
Mailing Address - Country:US
Mailing Address - Phone:520-586-9111
Mailing Address - Fax:520-586-9091
Practice Address - Street 1:300 S OCOTILLO AVE
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:AZ
Practice Address - Zip Code:85602-6401
Practice Address - Country:US
Practice Address - Phone:520-586-9111
Practice Address - Fax:520-586-9091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC-3070207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ27845Medicare PIN
AZZ85098Medicare PIN
AZZ28120Medicare PIN
AZQ27214Medicare UPIN
AZI21087Medicare UPIN
AZD43993Medicare UPIN
AZZ79699Medicare PIN