Basic Information
| Provider Information | |||||||||
| NPI: | 1336552140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARIZONA SPINE AND PAIN SPECIALISTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20280 N 59TH AVE STE 115-617 | ||||||||
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| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853086850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027958700 | ||||||||
| FaxNumber: | 6027958701 | ||||||||
| Practice Location | |||||||||
| Address1: | 7200 W BELL RD | ||||||||
| Address2: | STE F-101 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027958700 | ||||||||
| FaxNumber: | 6027958701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2014 | ||||||||
| LastUpdateDate: | 06/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | HOGAN | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 6027958700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 947192 | 05 | AZ | MEDICAID |