Provider Demographics
NPI:1669845558
Name:CASELLI AVENUE PROFESSIONALS LLC
Entity Type:Organization
Organization Name:CASELLI AVENUE PROFESSIONALS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-714-6783
Mailing Address - Street 1:9812 N 7TH ST
Mailing Address - Street 2:9812 N7TH STREET SUITE 7
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-1763
Mailing Address - Country:US
Mailing Address - Phone:602-714-6783
Mailing Address - Fax:602-325-0125
Practice Address - Street 1:9812 N 7TH ST
Practice Address - Street 2:9812 N. 7TH STREET
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-1763
Practice Address - Country:US
Practice Address - Phone:602-714-6783
Practice Address - Fax:602-325-0125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27081207R00000X, 207RB0002X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZWCSKQOtherSUN HEALTH GROUP
AZ445470Medicaid
AZZ24307Medicare PIN
AZWCSKQOtherSUN HEALTH GROUP