Provider Demographics
NPI:1033324538
Name:HEALTH EXCHANGE OF ARIZONA
Entity Type:Organization
Organization Name:HEALTH EXCHANGE OF ARIZONA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:I
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:602-265-9606
Mailing Address - Street 1:1130 E MISSOURI AVE
Mailing Address - Street 2:#404
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2718
Mailing Address - Country:US
Mailing Address - Phone:602-265-9606
Mailing Address - Fax:602-265-9605
Practice Address - Street 1:1130 E MISSOURI AVE
Practice Address - Street 2:#404
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2718
Practice Address - Country:US
Practice Address - Phone:602-265-9606
Practice Address - Fax:602-265-9605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ145187Medicaid