Basic Information
| Provider Information | |||||||||
| NPI: | 1891175188 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHOENIX SPINE GOODYEAR ASC, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHOENIX SPINE SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 N LITCHFIELD RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853381277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022562525 | ||||||||
| FaxNumber: | 6022560795 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 N LITCHFIELD RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022562525 | ||||||||
| FaxNumber: | 6022560795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2015 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LIEBERMAN | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6022562525 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | OSC7127 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 987125 | 05 | AZ | MEDICAID |