MEDICARE: SOUTH MOUNTAIN SURGERY CENTER, LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1073089215
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH MOUNTAIN SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	15810 S 45TH ST STE 150
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-7655
Country	:	US
Telephone Number	:	480-747-6240
Fax Number	:	480-747-6238

Provider Business Practice Location Address
First Line	:	15810 S 45TH ST STE 150
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-7655
Country	:	US
Telephone Number	:	480-747-6240
Fax Number	:	480-747-6238

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MIKE BURROLA
Credential	:
Telephone Number	:	623-302-0850

Provider Enumeration Date	:	10/15/2018
Last Update Date	:	01/22/2019

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