Provider Demographics
NPI:1669520268
Name:SURGICAL SPECIALTY IMAGING LLC
Entity type:Organization
Organization Name:SURGICAL SPECIALTY IMAGING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR V.P. & CHIEF ACCOUNTING OFCR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:DRAZBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-282-6000
Mailing Address - Street 1:26250 ENTERPRISE CT
Mailing Address - Street 2:STE 100
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-8406
Mailing Address - Country:US
Mailing Address - Phone:949-282-6000
Mailing Address - Fax:
Practice Address - Street 1:6501 N 19TH AVE
Practice Address - Street 2:STE A
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1646
Practice Address - Country:US
Practice Address - Phone:602-314-4280
Practice Address - Fax:602-314-4289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory