Provider Demographics
NPI:1144387978
Name:ARIZONA STATE UNIVERSITY
Entity Type:Organization
Organization Name:ARIZONA STATE UNIVERSITY
Other - Org Name:ASU HEALTH SERVICES DOWNTOWN NP HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:RNP
Authorized Official - Phone:602-496-0665
Mailing Address - Street 1:500 N 3RD ST
Mailing Address - Street 2:SUITE 155
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-2135
Mailing Address - Country:US
Mailing Address - Phone:602-496-0721
Mailing Address - Fax:602-496-0675
Practice Address - Street 1:500 N 3RD ST
Practice Address - Street 2:SUITE 155
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-2135
Practice Address - Country:US
Practice Address - Phone:602-496-0721
Practice Address - Fax:602-496-0675
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARIZONA STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-02
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ21383OtherMEDICARE PTAN
AZ207841Medicaid