Provider Demographics
NPI:1417986118
Name:INGENUITY MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:INGENUITY MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-296-6549
Mailing Address - Street 1:80 E RIO SALADO PKWY STE 703
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-9110
Mailing Address - Country:US
Mailing Address - Phone:480-247-9195
Mailing Address - Fax:480-588-8027
Practice Address - Street 1:1930 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7711
Practice Address - Country:US
Practice Address - Phone:480-296-6549
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ763484Medicaid
AZ763484Medicaid
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