1083643738 NPI number — DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM

Table of content: (NPI 1083643738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083643738 NPI number — DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PHOENIX INDIAN MEDICAL CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083643738
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 95460
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44101-0033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-581-6088
Provider Business Mailing Address Fax Number:
602-263-1619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4212 N 16TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85016-5319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-263-1200
Provider Business Practice Location Address Fax Number:
602-200-5383
Provider Enumeration Date:
07/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TILLMAN
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CMO
Authorized Official Telephone Number:
602-581-6080

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 537821 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P0206550 . This is a "BLUE CROSS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 418196 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 022062 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 092354 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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