Provider Demographics
NPI:1679682900
Name:NORTHWEST MEDICAL CENTER CT MRI AT MARANA LLC
Entity Type:Organization
Organization Name:NORTHWEST MEDICAL CENTER CT MRI AT MARANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, BUSINESS OFFICE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7466
Mailing Address - Street 1:8333 N SILVERBELL
Mailing Address - Street 2:SUITE 121
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85743
Mailing Address - Country:US
Mailing Address - Phone:520-202-7790
Mailing Address - Fax:
Practice Address - Street 1:8333 N SILVERBELL
Practice Address - Street 2:SUITE 121
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85743
Practice Address - Country:US
Practice Address - Phone:520-202-7790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPENDING261Q00000X, 261QM1200X, 261QM1300X, 261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPENDINGMedicaid
116984Medicare PIN