Provider Demographics
NPI:1386823854
Name:THE GLENDALE AZ ENDOSCOPY ASC LLC
Entity Type:Organization
Organization Name:THE GLENDALE AZ ENDOSCOPY ASC LLC
Other - Org Name:THUNDERBIRD ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1A BURTON HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-0000
Mailing Address - Country:US
Mailing Address - Phone:615-665-1283
Mailing Address - Fax:615-234-1720
Practice Address - Street 1:5823 W EUGIE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1276
Practice Address - Country:US
Practice Address - Phone:602-439-1717
Practice Address - Fax:602-938-0292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ119952Medicare PIN