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13991 W Grand Ave Suite 105 Surprise AZ 85374-3065 | |
| (623) 455-7800 | |
| (623) 455-7810 |
| Full Name | |
|---|---|
| Speciality | Clinic/center |
| Location | 13991 W Grand Ave, Surprise, Arizona |
| Authorized Official Name and Position | Kevin Ellis (CHEIF MEDICAL DIRECTOR) |
| Authorized Official Contact | 6023288400 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
8888 E Raintree Dr Fl 3 Scottsdale AZ 85260-3951 Ph: (602) 328-8400 | 13991 W Grand Ave Suite 105 Surprise AZ 85374-3065 Ph: (623) 455-7800 |
| NPI Number | 1033280698 |
|---|---|
| Provider Enumeration Date | 11/13/2006 |
| Last Update Date | 06/16/2023 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1033280698 | NPI | - | NPPES |
| 061763 | Medicaid | AZ |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | OTC 4547 (Arizona) | Primary |
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