Provider Demographics
NPI:1952765844
Name:STATESERV MEDICAL OF PHOENIX LLC
Entity Type:Organization
Organization Name:STATESERV MEDICAL OF PHOENIX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:ROODE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-633-7250
Mailing Address - Street 1:1201 SOUTH ALMA SCHOOL RD
Mailing Address - Street 2:SUITE 4000
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210
Mailing Address - Country:US
Mailing Address - Phone:623-777-4599
Mailing Address - Fax:623-777-4595
Practice Address - Street 1:220 E. GERMANN RD
Practice Address - Street 2:SUITE 110
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297
Practice Address - Country:US
Practice Address - Phone:877-633-7250
Practice Address - Fax:623-777-4595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ471068038332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies