Provider Demographics
NPI:1013975333
Name:SONORAN SPINE CENTER P.C.
Entity type:Organization
Organization Name:SONORAN SPINE CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DYLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-962-0071
Mailing Address - Street 1:1255 W RIO SALADO PKWY STE 107
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-2892
Mailing Address - Country:US
Mailing Address - Phone:480-962-0071
Mailing Address - Fax:480-962-0590
Practice Address - Street 1:1255 W RIO SALADO PKWY STE 105
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-2892
Practice Address - Country:US
Practice Address - Phone:602-443-6480
Practice Address - Fax:602-443-6499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ63464Medicare UPIN
AZ5912840001Medicare NSC