Provider Demographics
NPI:1528180874
Name:ARIZONA STATE PUBLIC HEALTH LABORATORY
Entity Type:Organization
Organization Name:ARIZONA STATE PUBLIC HEALTH LABORATORY
Other - Org Name:ADHS NEWBORN SCREENING PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUREAU CHIEF
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:WADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:602-364-0609
Mailing Address - Street 1:PO BOX 25046
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85002-5046
Mailing Address - Country:US
Mailing Address - Phone:602-542-0897
Mailing Address - Fax:602-542-0102
Practice Address - Street 1:250 N 17TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-3231
Practice Address - Country:US
Practice Address - Phone:602-542-0897
Practice Address - Fax:602-542-0102
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF ARIZONA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-06
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1Z4231OtherHEALTH NET
AZ186751OtherAHCCCS
AZAZ0727710OtherBLUECROSS/BLUESHIELD