1578035374 NPI number — SCOTTSDALE SPINE AND JOINT, LLC

Table of content: (NPI 1578035374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578035374 NPI number — SCOTTSDALE SPINE AND JOINT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SCOTTSDALE SPINE AND JOINT, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578035374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16211 N SCOTTSDALE RD STE A6A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCOTTSDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85254-1585
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-314-2288
Provider Business Mailing Address Fax Number:
480-314-1113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7010 E CHAUNCEY LN STE 215
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85054-3117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-314-2288
Provider Business Practice Location Address Fax Number:
480-314-1113
Provider Enumeration Date:
12/19/2018

Additional Information

Authorized Official

Authorized Official Last Name:
VENGURLEKAR
Authorized Official First Name:
SHAM
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
480-314-2288

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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