Provider Demographics
NPI:1437422425
Name:SUN VALLEY MEDICAL GROUP
Entity Type:Organization
Organization Name:SUN VALLEY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGROOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-935-7788
Mailing Address - Street 1:17215 N 72ND DR
Mailing Address - Street 2:SUITE C-125
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8558
Mailing Address - Country:US
Mailing Address - Phone:623-935-7788
Mailing Address - Fax:
Practice Address - Street 1:17215 N 72ND DR
Practice Address - Street 2:SUITE C-125
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8558
Practice Address - Country:US
Practice Address - Phone:623-935-7788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5917111N00000X
AZ4105207Q00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty