Provider Demographics
NPI:1801189519
Name:SRP FACILITY
Entity Type:Organization
Organization Name:SRP FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:R
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-889-9880
Mailing Address - Street 1:PO BOX 36395
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-9998
Mailing Address - Country:US
Mailing Address - Phone:602-889-9880
Mailing Address - Fax:
Practice Address - Street 1:3330 N 2ND ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2368
Practice Address - Country:US
Practice Address - Phone:602-889-9880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SRP FACILITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-27
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain