Provider Demographics
NPI:1205941093
Name:RAINBOW MEDICAL GROUP
Entity type:Organization
Organization Name:RAINBOW MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:623-845-8200
Mailing Address - Street 1:PO BOX 6524
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-0626
Mailing Address - Country:US
Mailing Address - Phone:623-845-8200
Mailing Address - Fax:623-845-8210
Practice Address - Street 1:4700 N 51ST AVE STE 1
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-1237
Practice Address - Country:US
Practice Address - Phone:623-845-8200
Practice Address - Fax:623-845-8210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty