Basic Information
| Provider Information | |||||||||
| NPI: | 1245239656 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SURGERY CENTER OF GILBERT LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SURGERY CENTER OF GILBERT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6003 E BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806416500 | ||||||||
| FaxNumber: | 4806416550 | ||||||||
| Practice Location | |||||||||
| Address1: | 6003 E BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806416500 | ||||||||
| FaxNumber: | 4806416550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 08/12/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4806416565 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | OSC3133 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 735722 | 05 | AZ | MEDICAID | 490005586 | 01 | AZ | RAILROAD MEDICARE | OTHER |