Provider Demographics
NPI:1003083551
Name:DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Entity Type:Organization
Organization Name:DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Other - Org Name:PIMC - AMBULATORY SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:MISS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:A
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-263-1674
Mailing Address - Street 1:PIMC ASC POBOX 95460
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0001
Mailing Address - Country:US
Mailing Address - Phone:602-581-6088
Mailing Address - Fax:602-263-1619
Practice Address - Street 1:4212 NORTH 16TH STREET
Practice Address - Street 2:PHOENIX INDIAN MEDICAL CENTER AMBULATORY SURGICAL CENT
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-263-1200
Practice Address - Fax:602-263-1618
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX INDIAN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-14
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAC0004Medicare UPIN