Provider Demographics
NPI:1073817490
Name:SCAN HEALTH IMAGING LLC
Entity Type:Organization
Organization Name:SCAN HEALTH IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANNTEJ
Authorized Official - Middle Name:
Authorized Official - Last Name:SRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-815-8200
Mailing Address - Street 1:13943 N 91ST AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-3629
Mailing Address - Country:US
Mailing Address - Phone:623-815-8200
Mailing Address - Fax:623-344-5458
Practice Address - Street 1:13943 N 91ST AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-3629
Practice Address - Country:US
Practice Address - Phone:623-815-8200
Practice Address - Fax:623-344-5458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ280332085R0202X
335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1Z8710OtherHEALTHNET PIN
AZ579394Medicaid
AZZ77385Medicare PIN