Provider Demographics
NPI:1205821097
Name:ADOBE SURGERY CENTER, PC
Entity Type:Organization
Organization Name:ADOBE SURGERY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUSSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-721-2728
Mailing Address - Street 1:2585 N WYATT DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-6104
Mailing Address - Country:US
Mailing Address - Phone:520-721-2728
Mailing Address - Fax:520-721-0179
Practice Address - Street 1:2585 N WYATT DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6104
Practice Address - Country:US
Practice Address - Phone:520-721-2728
Practice Address - Fax:520-721-0179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOSC3020261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ543456Medicaid
AZ63344Medicare ID - Type Unspecified