Provider Demographics
NPI:1598770380
Name:ADVANCED SURGICAL INSTITUTE P C
Entity Type:Organization
Organization Name:ADVANCED SURGICAL INSTITUTE P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:V
Authorized Official - Last Name:CANULLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-584-4882
Mailing Address - Street 1:14510 W SHUMWAY DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-5814
Mailing Address - Country:US
Mailing Address - Phone:623-584-4882
Mailing Address - Fax:623-584-6732
Practice Address - Street 1:14510 W SHUMWAY DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5814
Practice Address - Country:US
Practice Address - Phone:623-584-4882
Practice Address - Fax:623-584-6732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24230208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ348583Medicaid
AZG34372Medicare UPIN
AZ112387Medicare PIN