Provider Demographics
NPI:1952386062
Name:PHOENIX DIAGNOSTIC IMAGING INC
Entity Type:Organization
Organization Name:PHOENIX DIAGNOSTIC IMAGING INC
Other - Org Name:PHOENIX DIAGNOSTIC IMAGING FOUNTAINS
Other - Org Type:Other Name
Authorized Official - Title/Position:COO
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 1:5620 W THUNDERBIRD RD
Practice Address - Street 2:SUITE A
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4636
Practice Address - Country:US
Practice Address - Phone:602-863-9729
Practice Address - Fax:602-978-5940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-12
Last Update Date:2010-07-27
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
AZP00156014OtherRAILROAD MEDICARE
AZ67220Medicare ID - Type UnspecifiedIDTF