Provider Demographics
NPI:1104102482
Name:SEGO MEDICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:SEGO MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH-TRYON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-566-9958
Mailing Address - Street 1:3361 HILLDALE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-9062
Mailing Address - Country:US
Mailing Address - Phone:928-566-9958
Mailing Address - Fax:928-680-6522
Practice Address - Street 1:2082 MESQUITE AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6710
Practice Address - Country:US
Practice Address - Phone:928-680-4233
Practice Address - Fax:928-680-6522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZL-1712856-3OtherLLC REGISTRATION