Provider Demographics
NPI:1417071721
Name:MAGELLAN HEALTH SERVICES OF ARIZONA, INC.
Entity Type:Organization
Organization Name:MAGELLAN HEALTH SERVICES OF ARIZONA, INC.
Other - Org Name:MARICOPA CLINIC SOUTH CENTRAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:ADAIR
Authorized Official - Last Name:CARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-797-8333
Mailing Address - Street 1:4129 EAST VAN BUREN STREET
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008
Mailing Address - Country:US
Mailing Address - Phone:800-564-5465
Mailing Address - Fax:
Practice Address - Street 1:1616 E ROESER RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-3336
Practice Address - Country:US
Practice Address - Phone:602-323-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH2979251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ532061Medicaid
AZZ102026Medicare ID - Type Unspecified