Basic Information
| Provider Information | |||||||||
| NPI: | 1083851448 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HONORHEALTH AMBULATORY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SCOTTSDALE HEALTHCARE CORP. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 W UTOPIA RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806964020 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7351 E OSBORN RD | ||||||||
| Address2: | SUITE 200B | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852516451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808825730 | ||||||||
| FaxNumber: | 4808825755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2009 | ||||||||
| LastUpdateDate: | 09/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETRIDES | ||||||||
| AuthorizedOfficialFirstName: | SAVAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SVP/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4806964020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 401674 | 05 | AZ | MEDICAID |