Provider Demographics
NPI:1144629916
Name:ARIZONA SPORTS MEDICINE CENTER PLC
Entity type:Organization
Organization Name:ARIZONA SPORTS MEDICINE CENTER PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:480-889-1580
Mailing Address - Street 1:8630 E VIA DE VENTURA
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-3326
Mailing Address - Country:US
Mailing Address - Phone:480-558-3744
Mailing Address - Fax:480-558-3801
Practice Address - Street 1:8630 E VIA DE VENTURA
Practice Address - Street 2:SUITE 201
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-3326
Practice Address - Country:US
Practice Address - Phone:480-558-3744
Practice Address - Fax:480-558-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QS0010X
AZ207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty