Provider Demographics
NPI:1639133663
Name:ARIZONA DIAGNOSTIC IMAGING
Entity Type:Organization
Organization Name:ARIZONA DIAGNOSTIC IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-655-7517
Mailing Address - Street 1:456 N MESA DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-5913
Mailing Address - Country:US
Mailing Address - Phone:480-655-7517
Mailing Address - Fax:480-668-7546
Practice Address - Street 1:456 N MESA DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-5913
Practice Address - Country:US
Practice Address - Phone:480-655-7517
Practice Address - Fax:480-668-7546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ481820Medicaid
AZ0206340OtherBLUE CROSS
AZ1Z0924OtherHEALTH NET ID
AZ481820Medicaid