Provider Demographics
NPI:1770557233
Name:MESA AZ ENDOSCOPY ASC LLC
Entity type:Organization
Organization Name:MESA AZ ENDOSCOPY ASC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-969-0405
Mailing Address - Street 1:603 W BASELINE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6050
Mailing Address - Country:US
Mailing Address - Phone:480-969-0405
Mailing Address - Fax:480-969-2280
Practice Address - Street 1:603 W BASELINE RD STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6050
Practice Address - Country:US
Practice Address - Phone:480-969-0405
Practice Address - Fax:480-969-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOSC3651261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ860929359OtherTRI WEST - TRICARE
AZ03C0001278Medicare Oscar/Certification
AZ860929359OtherTRI WEST - TRICARE