Basic Information
Provider Information | |||||||||
NPI: | 1689100299 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PREMIER ENDOSCOPY ASC, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PREMIER ENDOSCOPY CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15305 DALLAS PKWY | ||||||||
Address2: | SUITE 1600 | ||||||||
City: | ADDISON | ||||||||
State: | TX | ||||||||
PostalCode: | 750014637 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9727633893 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2563 S VAL VISTA DR | ||||||||
Address2: | SUITE 101 | ||||||||
City: | GILBERT | ||||||||
State: | AZ | ||||||||
PostalCode: | 852951804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4807866655 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2017 | ||||||||
LastUpdateDate: | 05/03/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORAN | ||||||||
AuthorizedOfficialFirstName: | JENETHA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 9727633893 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.