Provider Demographics
NPI:1891905006
Name:ARIZONA CRANIOFACIAL & PLASTIC SURGERY CENTER PC
Entity Type:Organization
Organization Name:ARIZONA CRANIOFACIAL & PLASTIC SURGERY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:ALENE
Authorized Official - Last Name:WALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-905-9211
Mailing Address - Street 1:15721 N GREENWAY HAYDEN LOOP
Mailing Address - Street 2:#201
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-1650
Mailing Address - Country:US
Mailing Address - Phone:480-905-9211
Mailing Address - Fax:480-905-0504
Practice Address - Street 1:15721 N GREENWAY HAYDEN LOOP
Practice Address - Street 2:#201
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1650
Practice Address - Country:US
Practice Address - Phone:480-905-9211
Practice Address - Fax:480-905-0504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2008-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ239582086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ115054Medicare PIN
AZF86454Medicare UPIN
AZZ20432Medicare ID - Type Unspecified