1528180874 NPI number — ARIZONA STATE PUBLIC HEALTH LABORATORY

Table of content: (NPI 1528180874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528180874 NPI number — ARIZONA STATE PUBLIC HEALTH LABORATORY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARIZONA STATE PUBLIC HEALTH LABORATORY
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:
ADHS NEWBORN SCREENING PROGRAM
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:
1528180874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25046
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85002-5046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-542-0897
Provider Business Mailing Address Fax Number:
602-542-0102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 N 17TH AVE
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:
85007-3231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-542-0897
Provider Business Practice Location Address Fax Number:
602-542-0102
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WADDELL
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
BUREAU CHIEF
Authorized Official Telephone Number:
602-364-0609

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1Z4231 . This is a "HEALTH NET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 186751 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0727710 . This is a "BLUECROSS/BLUESHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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