Provider Demographics
NPI:1366796773
Name:MEDICAL GROUP OF ARIZONA, LLC
Entity type:Organization
Organization Name:MEDICAL GROUP OF ARIZONA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-686-8737
Mailing Address - Street 1:4616 N 51ST AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85031-1720
Mailing Address - Country:US
Mailing Address - Phone:480-686-8737
Mailing Address - Fax:602-216-3000
Practice Address - Street 1:13430 N. BLACK CANYON HIGHWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-1310
Practice Address - Country:US
Practice Address - Phone:602-943-9200
Practice Address - Fax:602-216-3000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29166207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty