Basic Information
| Provider Information | |||||||||
| NPI: | 1871985366 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL SERVICES OF SOUTHERN ARIZONA | ||||||||
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| OtherOrganizationName: | PIMA ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43160 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857333160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207223777 | ||||||||
| FaxNumber: | 5202966224 | ||||||||
| Practice Location | |||||||||
| Address1: | 6365 E TANQUE VERDE RD | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857153830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208861071 | ||||||||
| FaxNumber: | 5208813374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2015 | ||||||||
| LastUpdateDate: | 03/25/2015 | ||||||||
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| AuthorizedOfficialLastName: | BAEZ | ||||||||
| AuthorizedOfficialFirstName: | LE ROI | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5208861071 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 30154 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 001588 | 05 | AZ | MEDICAID |