Healthcare Provider Details

I. General information

NPI: 1700910270
Provider Name (Legal Business Name): ARIZONA MEDICAL SPINE INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4530 E RAY RD SUITE 150
PHOENIX AZ
85044-6094
US

IV. Provider business mailing address

4530 E RAY RD SUITE 150
PHOENIX AZ
85044-6094
US

V. Phone/Fax

Practice location:
  • Phone: 480-503-3344
  • Fax: 480-763-0417
Mailing address:
  • Phone: 480-503-3344
  • Fax: 480-763-0417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number20012
License Number StateAZ

VIII. Authorized Official

Name: DR. RANDALL PRUITT
Title or Position: PRESIDENT
Credential:
Phone: 480-503-3344