Basic Information
| Provider Information | |||||||||
| NPI: | 1760064885 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIX HEART AMBULATORY SURGERY AND ELECTROPHYSIOLOGY, LLC | ||||||||
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| OtherOrganizationName: | PHASE SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5859 W TALAVI BLVD STE 140 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853061871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028060357 | ||||||||
| FaxNumber: | 6239306060 | ||||||||
| Practice Location | |||||||||
| Address1: | 5859 W TALAVI BLVD STE 140 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853061871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022987777 | ||||||||
| FaxNumber: | 6239306060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2021 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | SHAKEEL | ||||||||
| AuthorizedOfficialMiddleName: | OSMAN | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6022987777 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.