Provider Demographics
NPI:1861855462
Name:SOUTH VAL VISTA MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:SOUTH VAL VISTA MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:VOGEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-497-2900
Mailing Address - Street 1:1450 W GUADALUPE RD
Mailing Address - Street 2:#120
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-3042
Mailing Address - Country:US
Mailing Address - Phone:480-926-7800
Mailing Address - Fax:480-926-2260
Practice Address - Street 1:754 S. VAL VISTA DR.
Practice Address - Street 2:#105
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296
Practice Address - Country:US
Practice Address - Phone:480-497-2900
Practice Address - Fax:480-926-2260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty