Basic Information
| Provider Information | |||||||||
| NPI: | 1467522987 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SCOTTSDALE CENTER FOR ADVANCED PAIN MANAGEMENT, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9500 E. IRONWOOD SQUARE DRIVE | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852584582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025703169 | ||||||||
| FaxNumber: | 6238888570 | ||||||||
| Practice Location | |||||||||
| Address1: | 9500 E. IRONWOOD SQUARE DRIVE | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852584582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806262552 | ||||||||
| FaxNumber: | 4806262551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 02/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | SANEL | ||||||||
| AuthorizedOfficialFirstName: | HENRY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4806618588 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 399234 | 05 | AZ | MEDICAID |