Provider Demographics
NPI:1891175188
Name:PHOENIX SPINE GOODYEAR ASC, LLC
Entity Type:Organization
Organization Name:PHOENIX SPINE GOODYEAR ASC, LLC
Other - Org Name:PHOENIX SPINE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MARKET PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-567-0269
Mailing Address - Street 1:2525 E ARIZONA BILTMORE CIR STE D142
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-2147
Mailing Address - Country:US
Mailing Address - Phone:602-256-2525
Mailing Address - Fax:602-256-0795
Practice Address - Street 1:140 N LITCHFIELD RD
Practice Address - Street 2:SUITE 110
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338
Practice Address - Country:US
Practice Address - Phone:602-256-2525
Practice Address - Fax:602-256-0795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-02
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOSC7127261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ987125Medicaid
AZZ75138Medicare PIN