Provider Demographics
NPI:1982005328
Name:SUN ARIZONA MEDICAL GROUP P.C.
Entity Type:Organization
Organization Name:SUN ARIZONA MEDICAL GROUP P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANNTEJ
Authorized Official - Middle Name:
Authorized Official - Last Name:SRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-815-8200
Mailing Address - Street 1:8380 W EMILE ZOLA AVE
Mailing Address - Street 2:SUITE E103
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4811
Mailing Address - Country:US
Mailing Address - Phone:602-529-4800
Mailing Address - Fax:602-529-4799
Practice Address - Street 1:7200 W BELL RD
Practice Address - Street 2:SUITE E103
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8529
Practice Address - Country:US
Practice Address - Phone:602-529-4800
Practice Address - Fax:602-529-4799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-04
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ171015OtherMEDICARE PTAN
AZ3323482OtherCIGNA/GREAT WEST
AZ944482OtherAHCCCS/MEDICAID