Provider Demographics
NPI:1588857486
Name:ARIZONA MEDICAL GROUP OF MESA, PC
Entity Type:Organization
Organization Name:ARIZONA MEDICAL GROUP OF MESA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-725-9060
Mailing Address - Street 1:9522 E SAN SALVADOR DR
Mailing Address - Street 2:SUITE 317
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5557
Mailing Address - Country:US
Mailing Address - Phone:480-725-9060
Mailing Address - Fax:480-525-2501
Practice Address - Street 1:9522 E SAN SALVADOR DR
Practice Address - Street 2:SUITE 317
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5557
Practice Address - Country:US
Practice Address - Phone:480-725-9060
Practice Address - Fax:480-525-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ117268Medicare PIN