Provider Demographics
NPI:1912187121
Name:ARIZONA STATE UNIVERSITY
Entity Type:Organization
Organization Name:ARIZONA STATE UNIVERSITY
Other - Org Name:ARIZONA STATE UNIVERSITY HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARKUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-965-1145
Mailing Address - Street 1:PO BOX 872104
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85287-2104
Mailing Address - Country:US
Mailing Address - Phone:480-727-1500
Mailing Address - Fax:480-727-1599
Practice Address - Street 1:7332 E. SUN DEVIL MALL
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212
Practice Address - Country:US
Practice Address - Phone:480-727-1500
Practice Address - Fax:480-727-1599
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARIZONA STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-06
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 363LF0000X
AZ207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty