Healthcare Provider Details

I. General information

NPI: 1720244973
Provider Name (Legal Business Name): INDEPENDENT SURGEONS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19424 N R H JOHNSON BLVD ST 101
SUN CITY WEST AZ
85375-1409
US

IV. Provider business mailing address

PO BOX 39179
PHOENIX AZ
85069-9179
US

V. Phone/Fax

Practice location:
  • Phone: 602-568-7114
  • Fax:
Mailing address:
  • Phone: 602-395-0718
  • Fax: 602-277-8146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: SHANNON WHITE
Title or Position: CREDENTIALING
Credential:
Phone: 602-395-0718