Healthcare Provider Details

I. General information

NPI: 1629351788
Provider Name (Legal Business Name): AMSURG NORTH VALLEY ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2011
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15255 N 40TH ST BLDG 8, SUITE 157
PHOENIX AZ
85032-4624
US

IV. Provider business mailing address

1A BURTON HILLS BLVD ATTN: PROVIDER ENROLLMENT
NASHVILLE TN
37215-6187
US

V. Phone/Fax

Practice location:
  • Phone: 602-482-1011
  • Fax: 602-482-0024
Mailing address:
  • Phone: 615-240-3809
  • Fax: 615-234-1809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateAZ

VIII. Authorized Official

Name: PHILLIP A CLENDENIN
Title or Position: PRESIDENT
Credential:
Phone: 615-665-1283