Provider Demographics
NPI:1972518652
Name:MOBILE ON-SITE MAMMOGRAPHY, INC.
Entity Type:Organization
Organization Name:MOBILE ON-SITE MAMMOGRAPHY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-955-4539
Mailing Address - Street 1:PO BOX 728
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97528-0063
Mailing Address - Country:US
Mailing Address - Phone:541-955-4539
Mailing Address - Fax:541-474-3884
Practice Address - Street 1:2005 W 14TH ST
Practice Address - Street 2:SUITE 134
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-6925
Practice Address - Country:US
Practice Address - Phone:480-967-3767
Practice Address - Fax:480-967-3787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0207XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ3M0000001Medicare PIN