Healthcare Provider Details

I. General information

NPI: 1508089624
Provider Name (Legal Business Name): 59TH AVENUE SURGICAL FACILITY, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8608 N 59TH AVE
GLENDALE AZ
85302-5404
US

IV. Provider business mailing address

8608 N 59TH AVE
GLENDALE AZ
85302-5404
US

V. Phone/Fax

Practice location:
  • Phone: 623-934-3211
  • Fax: 623-930-1891
Mailing address:
  • Phone: 623-934-3211
  • Fax: 623-930-1891

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. MARK RICHARD GORMAN
Title or Position: C.E.O.
Credential: D.P.M.
Phone: 623-934-3211