Basic Information
Provider Information | |||||||||
NPI: | 1093018053 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BARNET DULANEY SURGERY CENTERS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SEDONA SURGERY CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4800 N 22ND ST | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850164701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029551000 | ||||||||
FaxNumber: | 6025084830 | ||||||||
Practice Location | |||||||||
Address1: | 95 SOLDIERS PASS RD | ||||||||
Address2: | SUITE A-2 | ||||||||
City: | SEDONA | ||||||||
State: | AZ | ||||||||
PostalCode: | 863364781 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282031177 | ||||||||
FaxNumber: | 9282031750 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/14/2010 | ||||||||
LastUpdateDate: | 12/14/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SNYDER | ||||||||
AuthorizedOfficialFirstName: | DONALD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6029551000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 3747 | AZ | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
ID | Type | State | Issuer | Description | 3747 | 01 | AZ | LICENSE | OTHER |