Basic Information
| Provider Information | |||||||||
| NPI: | 1700434347 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IVY ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 41150 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852741150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804252160 | ||||||||
| FaxNumber: | 4803518797 | ||||||||
| Practice Location | |||||||||
| Address1: | 7303 E LA JUNTA RD | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852552806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804252160 | ||||||||
| FaxNumber: | 4803518797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2019 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | ASSAD | ||||||||
| AuthorizedOfficialFirstName: | SAMEH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4804252160 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 34025 | 01 | AZ | ARIZONA MEDICAL BOARD | OTHER |