Provider Demographics
NPI:1104014257
Name:SIERRA VISTA DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:SIERRA VISTA DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:I
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-459-5227
Mailing Address - Street 1:155 CALLE PORTAL STE 500
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2973
Mailing Address - Country:US
Mailing Address - Phone:520-459-5227
Mailing Address - Fax:520-459-2191
Practice Address - Street 1:155 CALLE PORTAL STE 500
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2973
Practice Address - Country:US
Practice Address - Phone:520-459-5227
Practice Address - Fax:520-459-2191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ91102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ255085001Medicaid
AZDD8752OtherRAILROAD MEDICARE
AZ220575001Medicaid
AZZ104592Medicare PIN
AZD37142Medicare UPIN
AZ255085001Medicaid