Provider Demographics
NPI:1770148322
Name:EQUALITY MEDICAL GROUP LLC
Entity type:Organization
Organization Name:EQUALITY MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATA-ESPINOZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-687-8219
Mailing Address - Street 1:4220 N 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-5124
Mailing Address - Country:US
Mailing Address - Phone:602-889-9401
Mailing Address - Fax:602-889-9404
Practice Address - Street 1:9020 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3234
Practice Address - Country:US
Practice Address - Phone:580-686-0282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-08
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ530088Medicaid