MEDICARE: HAVASU SURGICAL SPECIALISTS, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	31136	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063629087
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVASU SURGICAL SPECIALISTS, PC

Provider Business Mailing Address
First Line	:	1972 MESQUITE AVE
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5729
Country	:	US
Telephone Number	:	928-854-6508
Fax Number	:	928-854-6206

Provider Business Practice Location Address
First Line	:	1972 MESQUITE AVE
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5729
Country	:	US
Telephone Number	:	928-854-6508
Fax Number	:	928-854-6206

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	CARRIE L RIESDORPH
Credential	:
Telephone Number	:	928-854-6508

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	08/22/2020

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