Provider Demographics
NPI:1871209494
Name:R DEROSA SURGERY LLC
Entity type:Organization
Organization Name:R DEROSA SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-975-9847
Mailing Address - Street 1:6225 E DUSTY COYOTE CIR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85266-7201
Mailing Address - Country:US
Mailing Address - Phone:703-975-9847
Mailing Address - Fax:
Practice Address - Street 1:18701 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7100
Practice Address - Country:US
Practice Address - Phone:623-561-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty