Provider Demographics
NPI:1538113238
Name:ADVANCED LASER & SURGICENTER OF ARIZONA, PC
Entity type:Organization
Organization Name:ADVANCED LASER & SURGICENTER OF ARIZONA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIANOUSH
Authorized Official - Middle Name:
Authorized Official - Last Name:KIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-632-2020
Mailing Address - Street 1:3303 E BASELINE RD
Mailing Address - Street 2:#104
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2739
Mailing Address - Country:US
Mailing Address - Phone:480-632-2020
Mailing Address - Fax:480-632-2121
Practice Address - Street 1:3303 E BASELINE RD
Practice Address - Street 2:#104
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2739
Practice Address - Country:US
Practice Address - Phone:480-632-2020
Practice Address - Fax:480-632-2121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOSC3540261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0209500OtherBCBS OF AZ
AZ0209500OtherTRICARE
AZ907610OtherAZ HEALTH CARE COST SYS
AZIZ0620OtherHEALTH NET INS
AZ0209500OtherTRICARE