Provider Demographics
NPI:1124003231
Name:PHOENIX DIAGNOSTIC IMAGING INC
Entity Type:Organization
Organization Name:PHOENIX DIAGNOSTIC IMAGING INC
Other - Org Name:PHOENIX DIAGNOSTIC IMAGING SUPERSTITION
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-264-2400
Mailing Address - Street 1:PO BOX 7368
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-7368
Mailing Address - Country:US
Mailing Address - Phone:714-571-5000
Mailing Address - Fax:714-571-5055
Practice Address - Street 1:875 N GREENFIELD RD
Practice Address - Street 2:SUITE 107
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-5044
Practice Address - Country:US
Practice Address - Phone:480-813-8700
Practice Address - Fax:480-813-8707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-12
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00156014OtherRAILROAD MEDICARE
AZ75883Medicare ID - Type UnspecifiedIDTF