Provider Demographics
NPI:1518137520
Name:PHYSICIAN GROUP OF ARIZONA INC
Entity Type:Organization
Organization Name:PHYSICIAN GROUP OF ARIZONA INC
Other - Org Name:STEWARD MEDICAL GROUP OF ARIZONA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-562-7070
Mailing Address - Street 1:PO BOX 281201
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1201
Mailing Address - Country:US
Mailing Address - Phone:866-243-7104
Mailing Address - Fax:314-432-9683
Practice Address - Street 1:4801 E WASHINGTON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-2004
Practice Address - Country:US
Practice Address - Phone:602-507-4500
Practice Address - Fax:602-688-8311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ323426Medicaid
AZ323426Medicaid