Provider Demographics
NPI:1972578367
Name:YUMA AZ ENDOSCOPY ASC LLC
Entity type:Organization
Organization Name:YUMA AZ ENDOSCOPY ASC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLENDENIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1030 W 24TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-8384
Mailing Address - Country:US
Mailing Address - Phone:928-343-1717
Mailing Address - Fax:928-343-1011
Practice Address - Street 1:1030 W 24TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8384
Practice Address - Country:US
Practice Address - Phone:928-343-1717
Practice Address - Fax:928-343-1011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOSC 3889261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ116880Medicaid
AZZ106442Medicare PIN
AZ116880Medicaid
AZ03C0001241Medicare Oscar/Certification