Provider Demographics
NPI:1679628531
Name:DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Entity Type:Organization
Organization Name:DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Other - Org Name:SALT RIVER PROFESSIONAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:A
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-263-1674
Mailing Address - Street 1:PO BOX 95460
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-0033
Mailing Address - Country:US
Mailing Address - Phone:602-581-6088
Mailing Address - Fax:602-263-1619
Practice Address - Street 1:10005 E OSBORN RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85256-4019
Practice Address - Country:US
Practice Address - Phone:602-263-1200
Practice Address - Fax:602-263-1618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP0109880OtherBCBSAZ
AZ092353Medicaid
AZP0109880OtherBCBSAZ
AZG=========OtherBCBSAZ
AZP0109880OtherBCBSAZ