Provider Demographics
NPI:1679747026
Name:OAK STREET
Entity Type:Organization
Organization Name:OAK STREET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:
Authorized Official - Last Name:EDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-914-5859
Mailing Address - Street 1:2255 N 44TH ST STE 240
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-7233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2255 N 44TH ST STE 240
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-7233
Practice Address - Country:US
Practice Address - Phone:602-914-5859
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VO OF ARIZONA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-1903251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ805418Medicaid