Provider Demographics
NPI:1659404176
Name:PORTABLE X RAY OF ARIZONA LLC
Entity Type:Organization
Organization Name:PORTABLE X RAY OF ARIZONA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ABBY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-395-5011
Mailing Address - Street 1:5538 DUNCAN DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-2812
Mailing Address - Country:US
Mailing Address - Phone:702-395-5011
Mailing Address - Fax:702-645-2874
Practice Address - Street 1:2338 W ROYAL PALM RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-9339
Practice Address - Country:US
Practice Address - Phone:602-864-3656
Practice Address - Fax:602-864-3660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ579055OtherAHCCS
AZ579055OtherHEALTHCHOICE
AZAW2888OtherHEALTHNET
AZF10081OtherPHOENIX HEALTH PLAN
AZ2Z1598OtherHEALTH NET
AZ579055Medicaid
AZ67270OtherSCAN
AZAZ0890990OtherBLUE CROSS BLUE SHILED OF
AZZ67270Medicare PIN