Basic Information
| Provider Information | |||||||||
| NPI: | 1124163530 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORTHOPEDIC AND SURGICAL SPECIALTY COMPANY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ARIZONA SPECIALTY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14201 DALLAS PKWY | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752542916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727633859 | ||||||||
| FaxNumber: | 4806039107 | ||||||||
| Practice Location | |||||||||
| Address1: | 2905 W WARNER RD | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852241674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806039000 | ||||||||
| FaxNumber: | 4806039107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOON | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 4805670269 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | N | Hospitals | General Acute Care Hospital | 284300000X | SH3571 | AZ | Y | Hospitals | Special Hospital |
ID Information
| ID | Type | State | Issuer | Description | 882747 | 05 | AZ | MEDICAID |