Provider Demographics
NPI:1932608106
Name:STAR CLINIC LLC
Entity Type:Organization
Organization Name:STAR CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR OF ANESTHESIA RCM
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-268-9195
Mailing Address - Street 1:PO BOX 26904
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85068-6904
Mailing Address - Country:US
Mailing Address - Phone:480-596-8525
Mailing Address - Fax:480-596-8522
Practice Address - Street 1:14155 N 83RD AVE
Practice Address - Street 2:BUILDING 6
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381
Practice Address - Country:US
Practice Address - Phone:623-223-0689
Practice Address - Fax:480-289-2712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-02
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22281207L00000X
AZ38152207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive SurgeryGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ335672Medicaid