Provider Demographics
NPI:1407026651
Name:SAGE MEMORIAL HOSPITAL BEHAVIORAL HEALTH CLINIC
Entity Type:Organization
Organization Name:SAGE MEMORIAL HOSPITAL BEHAVIORAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:R
Authorized Official - Last Name:RAZAGHI
Authorized Official - Suffix:
Authorized Official - Credentials:ME, MBA
Authorized Official - Phone:928-755-4500
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:GANADO
Mailing Address - State:AZ
Mailing Address - Zip Code:86505-0457
Mailing Address - Country:US
Mailing Address - Phone:928-755-4500
Mailing Address - Fax:928-755-4747
Practice Address - Street 1:HIGHWAY 264 AND 191
Practice Address - Street 2:SALSBURY HALL SAGE MEMORIAL HOSPITAL CAMPUS
Practice Address - City:GANADO
Practice Address - State:AZ
Practice Address - Zip Code:86505
Practice Address - Country:US
Practice Address - Phone:928-755-4500
Practice Address - Fax:928-755-4747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5168T101Y00000X
AZ13084101Y00000X
AZ11643104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ942757Medicaid