Healthcare Provider Details

I. General information

NPI: 1497253546
Provider Name (Legal Business Name): LAYNE SANDRIDGE MD, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 03/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18700 N 64TH DR STE 105A
GLENDALE AZ
85308-7110
US

IV. Provider business mailing address

19801 N 59TH AVE #11659
GLENDALE AZ
85318
US

V. Phone/Fax

Practice location:
  • Phone: 623-688-5075
  • Fax: 623-688-5075
Mailing address:
  • Phone: 623-688-5075
  • Fax: 602-842-9970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: LAYNE C. SANDRIDGE
Title or Position: PHYSICIAN/PRACTICE OWNER
Credential: MD
Phone: 623-688-5075