Provider Demographics
NPI:1790759355
Name:BANNER ARIZONA ASC LLC
Entity Type:Organization
Organization Name:BANNER ARIZONA ASC LLC
Other - Org Name:THE JON R. HILLEGAS SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLENDENIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:13640 N PLAZA DEL RIO BLVD
Mailing Address - Street 2:SUITE 135
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4846
Mailing Address - Country:US
Mailing Address - Phone:623-876-3943
Mailing Address - Fax:623-876-6946
Practice Address - Street 1:13640 N PLAZA DEL RIO BLVD
Practice Address - Street 2:SUITE 135
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4846
Practice Address - Country:US
Practice Address - Phone:623-876-3943
Practice Address - Fax:623-876-6946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOSC3316261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03-C0001070Medicare Oscar/Certification
AZZ72751Medicare PIN
AZ490005765Medicare PIN