Provider Demographics
NPI:1992706899
Name:SURGERY CENTER OF PEORIA, LLC
Entity type:Organization
Organization Name:SURGERY CENTER OF PEORIA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
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 1:13260 N 94TH DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4828
Mailing Address - Country:US
Mailing Address - Phone:623-933-2900
Mailing Address - Fax:623-933-0017
Practice Address - Street 1:13260 N 94TH DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4828
Practice Address - Country:US
Practice Address - Phone:623-933-2900
Practice Address - Fax:623-933-0017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2025-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOSC0016261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ436883Medicaid
AZ490003885OtherRAILROAD MEDICARE
AZ490003885OtherRAILROAD MEDICARE
AZ03C0001016Medicare Oscar/Certification