Provider Demographics
NPI:1356594626
Name:EAST VALLEY NEUROSURGERY, LLC
Entity type:Organization
Organization Name:EAST VALLEY NEUROSURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:FARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-478-6620
Mailing Address - Street 1:2045 S VINEYARD
Mailing Address - Street 2:142
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6889
Mailing Address - Country:US
Mailing Address - Phone:480-303-6010
Mailing Address - Fax:480-507-0019
Practice Address - Street 1:2045 S VINEYARD
Practice Address - Street 2:142
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6889
Practice Address - Country:US
Practice Address - Phone:480-303-6010
Practice Address - Fax:480-507-0019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-29
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ128962Medicare PIN