Provider Demographics
NPI:1346718582
Name:IVY LEAGUE ANESTHESIA PLLC
Entity Type:Organization
Organization Name:IVY LEAGUE ANESTHESIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMEH
Authorized Official - Middle Name:
Authorized Official - Last Name:ASSAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-405-9985
Mailing Address - Street 1:7878 N 16TH ST STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4478
Mailing Address - Country:US
Mailing Address - Phone:602-308-7802
Mailing Address - Fax:
Practice Address - Street 1:7878 N 16TH ST STE 250
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4478
Practice Address - Country:US
Practice Address - Phone:602-308-7802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ943622Medicaid