Provider Demographics
NPI:1457326589
Name:PET SCAN ARIZONA LLC
Entity Type:Organization
Organization Name:PET SCAN ARIZONA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-566-3777
Mailing Address - Street 1:PO BOX 27340
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85061-7340
Mailing Address - Country:US
Mailing Address - Phone:602-943-9200
Mailing Address - Fax:602-216-3000
Practice Address - Street 1:13460 N 94TH DR
Practice Address - Street 2:SUITE J-1
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4835
Practice Address - Country:US
Practice Address - Phone:623-566-3777
Practice Address - Fax:623-566-1216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ555386Medicaid
AZ1Z7140OtherHEALTH NET OF AZ
AZAZ0891570OtherBCBSAZ
AZ1Z7140OtherHEALTH NET OF AZ