=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598226268
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGICAL & PAIN CENTER OF SCOTTSDALE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2019
-----------------------------------------------------
Last Update Date | 08/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2629 N SCOTTSDALE RD STE 101
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85257-1370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-550-6493
-----------------------------------------------------
Fax | 602-297-6997
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2629 N SCOTTSDALE RD STE 100
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85257-1370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-510-3203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | SAM FARNOUSH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 602-882-3683
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------