Provider Demographics
NPI:1497253546
Name:LAYNE SANDRIDGE MD, PLC
Entity Type:Organization
Organization Name:LAYNE SANDRIDGE MD, PLC
Other - Org Name:VALLEY VASCULAR SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAYNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SANDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-688-5075
Mailing Address - Street 1:19801 N 59TH AVE
Mailing Address - Street 2:#11659
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85318
Mailing Address - Country:US
Mailing Address - Phone:623-688-5075
Mailing Address - Fax:602-842-9970
Practice Address - Street 1:18700 N 64TH DR STE 105A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7110
Practice Address - Country:US
Practice Address - Phone:623-688-5075
Practice Address - Fax:623-688-5075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-23
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ443661Medicaid