=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750384822
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGICAL SPECIALTIES OF CASA GRANDE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1760 E FLORENCE BLVD BLDG 2
-----------------------------------------------------
City | CASA GRANDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85222-4776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-421-2300
-----------------------------------------------------
Fax | 520-421-2411
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1760 E FLORENCE BLVD BLDG 2
-----------------------------------------------------
City | CASA GRANDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85222-4776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-421-2300
-----------------------------------------------------
Fax | 520-421-2411
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. BERNARD-DEAN FRANK MARUCCI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 520-421-2300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | OSC-3188
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------