Basic Information
| Provider Information | |||||||||
| NPI: | 1659731669 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHOENIX ASC, LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CARDIAC SURGERY CENTER OF PHOENIX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1910 E THOMAS RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850167766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 4849240053 | ||||||||
| Practice Location | |||||||||
| Address1: | 1910 E THOMAS RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850167766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138127586 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2016 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | GREGG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6106448900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.