Healthcare Provider Details

I. General information

NPI: 1437795598
Provider Name (Legal Business Name): PAIN SPECIALTY SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 E BASELINE RD STE 104
GILBERT AZ
85234-2739
US

IV. Provider business mailing address

3370 S MERCY RD STE 321
GILBERT AZ
85297-0417
US

V. Phone/Fax

Practice location:
  • Phone: 480-550-9393
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. AHDEV KUPPUSAMY
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: MD
Phone: 480-550-9393