1750384822 NPI number — SURGICAL SPECIALTIES OF CASA GRANDE

Table of content: (NPI 1750384822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750384822 NPI number — SURGICAL SPECIALTIES OF CASA GRANDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURGICAL SPECIALTIES OF CASA GRANDE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750384822
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1760 E FLORENCE BLVD
Provider Second Line Business Mailing Address:
BLDG 2
Provider Business Mailing Address City Name:
CASA GRANDE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85222-4776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-421-2300
Provider Business Mailing Address Fax Number:
520-421-2411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1760 E FLORENCE BLVD
Provider Second Line Business Practice Location Address:
BLDG 2
Provider Business Practice Location Address City Name:
CASA GRANDE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85222-4776
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-421-2300
Provider Business Practice Location Address Fax Number:
520-421-2411
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MARUCCI
Authorized Official First Name:
BERNARD-DEAN
Authorized Official Middle Name:
FRANK
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
520-421-2300

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  OSC-3188 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 750697 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com