Provider Demographics
NPI:1588647432
Name:PORTABLE XRAY OF ARIZONA PHOENIX
Entity Type:Organization
Organization Name:PORTABLE XRAY OF ARIZONA PHOENIX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR CORPORATE SUPPORT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBBIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-939-6559
Mailing Address - Street 1:2338 W. ROYAL PALM AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029
Mailing Address - Country:US
Mailing Address - Phone:602-864-3656
Mailing Address - Fax:602-864-0386
Practice Address - Street 1:2338 W. ROYAL PALM AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029
Practice Address - Country:US
Practice Address - Phone:602-864-3656
Practice Address - Fax:602-864-0386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ579055Medicaid
AZ579055Medicaid