Basic Information
Provider Information | |||||||||
NPI: | 1780140772 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADIOS ESTENOSIS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AZURA SURGERY CENTER LAS VEGAS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 40 VALLEY STREAM PKWY STE 100 | ||||||||
Address2: |   | ||||||||
City: | MALVERN | ||||||||
State: | PA | ||||||||
PostalCode: | 193551407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6106448900 | ||||||||
FaxNumber: | 4849240053 | ||||||||
Practice Location | |||||||||
Address1: | 2450 FIRE MESA ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891289001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7027266344 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/14/2019 | ||||||||
LastUpdateDate: | 06/24/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RUDNITSKY | ||||||||
AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 7027266344 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
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.