Provider Demographics
NPI:1023093135
Name:PHOENIX DIAGNOSTIC IMAGING INC
Entity type:Organization
Organization Name:PHOENIX DIAGNOSTIC IMAGING INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-300-0101
Mailing Address - Street 1:PO BOX 52527
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072-2527
Mailing Address - Country:US
Mailing Address - Phone:480-545-0113
Mailing Address - Fax:480-545-4267
Practice Address - Street 1:3201 W PEORIA AVE
Practice Address - Street 2:SUITE B404
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4608
Practice Address - Country:US
Practice Address - Phone:602-336-8600
Practice Address - Fax:602-942-8716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ67222Medicare ID - Type UnspecifiedIDTF