1558459438 NPI number — DESERT VALLEY RADIOLOGY, PLC

Table of content: (NPI 1558459438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558459438 NPI number — DESERT VALLEY RADIOLOGY, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT VALLEY RADIOLOGY, PLC
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:
Provider Other Organization Name Type Code:
6
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:
1558459438
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4045 E. BELL RD.
Provider Second Line Business Mailing Address:
STE. 143
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85032-2245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-867-0404
Provider Business Mailing Address Fax Number:
602-788-0893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8380 S. KYRENE
Provider Second Line Business Practice Location Address:
STE. 105
Provider Business Practice Location Address City Name:
TEMPE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85284-2120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-785-2511
Provider Business Practice Location Address Fax Number:
480-705-4431
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WALL III
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
602-867-0404

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 333218 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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