Provider Demographics
NPI:1629013263
Name:ARIZONA STATE UNIVERSITY
Entity Type:Organization
Organization Name:ARIZONA STATE UNIVERSITY
Other - Org Name:ARIZONA STATE UNIVERSITY HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEFANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHROEDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-965-4356
Mailing Address - Street 1:PO BOX 872104
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85287-2104
Mailing Address - Country:US
Mailing Address - Phone:480-965-3346
Mailing Address - Fax:480-965-2269
Practice Address - Street 1:451 E UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-5390
Practice Address - Country:US
Practice Address - Phone:480-965-3346
Practice Address - Fax:480-965-2269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ113682Medicaid