Provider Demographics
NPI:1083616569
Name:P.E.T. SCAN ARIZONA LLC
Entity Type:Organization
Organization Name:P.E.T. SCAN ARIZONA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:602-589-7226
Mailing Address - Street 1:PO BOX 27340
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85061-7340
Mailing Address - Country:US
Mailing Address - Phone:602-943-9200
Mailing Address - Fax:602-216-3000
Practice Address - Street 1:6036 N 19TH AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2106
Practice Address - Country:US
Practice Address - Phone:602-589-7226
Practice Address - Fax:602-589-0816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1083616569OtherNPI
AZ555386Medicaid
AZAZ0891570OtherBCBS AZ
AZ1Z7140OtherHEALTH NET
AZZ66860Medicare PIN