Provider Demographics
NPI:1730138413
Name:WABASH MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:WABASH MEDICAL ASSOCIATES PC
Other - Org Name:SUN CITY WEST INTERNAL MEDICINE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JAGDEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:BAINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-544-6963
Mailing Address - Street 1:13927 W GRAND AVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-2438
Mailing Address - Country:US
Mailing Address - Phone:623-544-6963
Mailing Address - Fax:623-975-5486
Practice Address - Street 1:13927 W GRAND AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2438
Practice Address - Country:US
Practice Address - Phone:623-544-6963
Practice Address - Fax:623-975-5486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29311207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ66796Medicare ID - Type Unspecified