Provider Demographics
| NPI: | 1184738049 |
|---|---|
| Name: | DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM. |
| Entity type: | Organization |
| Organization Name: | DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM. |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CMO |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | LAURA |
| Authorized Official - Middle Name: | A |
| Authorized Official - Last Name: | TILLMAN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MD |
| Authorized Official - Phone: | 602-263-1674 |
| Mailing Address - Street 1: | PO BOX 95460 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | CLEVELAND |
| Mailing Address - State: | OH |
| Mailing Address - Zip Code: | 44193-0698 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 602-581-6088 |
| Mailing Address - Fax: | 602-263-1619 |
| Practice Address - Street 1: | 4212 N 16TH ST |
| Practice Address - Street 2: | |
| Practice Address - City: | PHOENIX |
| Practice Address - State: | AZ |
| Practice Address - Zip Code: | 85016-5319 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 602-263-1200 |
| Practice Address - Fax: | 602-263-1618 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | PHOENIX INDIAN MEDICAL CENTER |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2006-08-18 |
| Last Update Date: | 2021-05-26 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207K00000X | Allopathic & Osteopathic Physicians | Allergy & Immunology | Group - Multi-Specialty | |
| No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | Group - Multi-Specialty | |
| No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
| No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
| No | 207ZP0101X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | Group - Multi-Specialty |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| AZ | 092354 | Medicaid | |
| AZ | 418196 | Medicaid | |
| AZ | P206550 | Other | BCBSAZ |
| AZ | 022062 | Medicaid | |
| AZ | 022062 | Medicaid | |
| AZ | 092354 | Medicaid | |
| AZ | HSZ080 | Medicare UPIN |
