Provider Demographics
NPI:1518932110
Name:MODERN DIAGNOSTIC IMAGING PC
Entity Type:Organization
Organization Name:MODERN DIAGNOSTIC IMAGING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEETAL
Authorized Official - Middle Name:G
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-445-9961
Mailing Address - Street 1:600 S DOBSON RD
Mailing Address - Street 2:B16
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5678
Mailing Address - Country:US
Mailing Address - Phone:480-445-9961
Mailing Address - Fax:480-445-9972
Practice Address - Street 1:600 S DOBSON RD
Practice Address - Street 2:B16
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5678
Practice Address - Country:US
Practice Address - Phone:480-445-9961
Practice Address - Fax:480-445-9972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0153760OtherBCBSAZ
AZ181760Medicaid
AZ2Z2341OtherHEALTH NET OF ARIZONA
AZP00310142Medicare PIN
AZ181760Medicaid