Provider Demographics
NPI:1356570378
Name:ARIZONA CLINIC OF GASTROENTEROLOGY PC
Entity type:Organization
Organization Name:ARIZONA CLINIC OF GASTROENTEROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:R
Authorized Official - Last Name:PEIRSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:877-283-4714
Mailing Address - Street 1:PO BOX 5819
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85385-5819
Mailing Address - Country:US
Mailing Address - Phone:877-283-4714
Mailing Address - Fax:623-444-5495
Practice Address - Street 1:13934 N 59TH AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4167
Practice Address - Country:US
Practice Address - Phone:877-283-4714
Practice Address - Fax:623-444-5495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-12
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31649207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ469524Medicaid
AZ134782Medicare PIN