Provider Demographics
NPI:1093739740
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:SALT RIVER FACILITY
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:PO BOX 95460
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-0033
Mailing Address - Country:US
Mailing Address - Phone:602-581-6088
Mailing Address - Fax:602-263-1619
Practice Address - Street 1:10005 E OSBORN RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85256-4019
Practice Address - Country:US
Practice Address - Phone:602-263-1200
Practice Address - Fax:602-263-1618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ092453Medicaid
AZP0109880OtherBCBS
AZG=========OtherBC BS DENTAL
AZ092453Medicaid
AZHSZ081Medicare ID - Type UnspecifiedPART B