MEDICARE: ELK RIDGE SURGICAL SPECIALISTS PLLC

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	2086S0129X	Vascular Surgery Physician	4778	AZ

General Provider Information

NPI Number	:	1588833594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELK RIDGE SURGICAL SPECIALISTS PLLC

Provider Business Mailing Address
First Line	:	5448 WHITE MOUNTAIN BLVD
Second Line	:	SUITE 210
City	:	LAKESIDE
State	:	AZ
Zip	:	85929-5739
Country	:	US
Telephone Number	:	928-537-8285
Fax Number	:	928-537-8291

Provider Business Practice Location Address
First Line	:	5448 WHITE MOUNTAIN BLVD
Second Line	:	SUITE 210
City	:	LAKESIDE
State	:	AZ
Zip	:	85929-5739
Country	:	US
Telephone Number	:	928-537-8285
Fax Number	:	928-537-8291

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. EDWIN VINCENT WEHLING
Credential	:	D.O.
Telephone Number	:	928-537-8285

Provider Enumeration Date	:	02/23/2008
Last Update Date	:	03/26/2014

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