=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902807159
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGERY CENTER OF SCOTTSDALE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2005
-----------------------------------------------------
Last Update Date | 01/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8962 E DESERT COVE AVE
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-6984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-661-5232
-----------------------------------------------------
Fax | 480-661-5231
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8962 E DESERT COVE AVE STE 120A
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-6984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-661-5232
-----------------------------------------------------
Fax | 480-661-5231
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER/AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | ERIC BOON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-567-0269
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | OSC 2894
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------