Provider Demographics
NPI:1164434098
Name:EAST VALLEY DIAGNOSTIC IMAGING LLC
Entity Type:Organization
Organization Name:EAST VALLEY DIAGNOSTIC IMAGING LLC
Other - Org Name:EVDI MEDICAL IMAGING, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:MARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-272-8004
Mailing Address - Street 1:1125 E. SOUTHERN AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-5046
Mailing Address - Country:US
Mailing Address - Phone:480-545-8119
Mailing Address - Fax:480-926-8332
Practice Address - Street 1:1125 E. SOUTHERN AVE
Practice Address - Street 2:STE 200
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5046
Practice Address - Country:US
Practice Address - Phone:480-545-8119
Practice Address - Fax:480-926-8332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ585681Medicaid
AZH66826Medicare UPIN
AZ585681Medicaid