Basic Information
| Provider Information | |||||||||
| NPI: | 1285082388 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ARIZONA SPINE AND PAIN SPECIALISTS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | AZ PAIN DOCTORS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20280 N 59TH AVE # 115-617 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853086850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0267958700 | ||||||||
| FaxNumber: | 6027958701 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 N LITCHFIELD RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853951213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027958700 | ||||||||
| FaxNumber: | 6027958701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2016 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | HOGAN | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER/MANAGING EMPLOYEE | ||||||||
| AuthorizedOfficialTelephone: | 6027958700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | AZ | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 947192 | 05 | AZ | MEDICAID | Z172895 | 01 | AZ | MEDICARE PTAN | OTHER |