Basic Information
| Provider Information | |||||||||
| NPI: | 1164434098 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST VALLEY DIAGNOSTIC IMAGING LLC | ||||||||
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| OtherOrganizationName: | EVDI MEDICAL IMAGING, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 E. SOUTHERN AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852045046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805458119 | ||||||||
| FaxNumber: | 4809268332 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 E. SOUTHERN AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852045046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805458119 | ||||||||
| FaxNumber: | 4809268332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 07/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | MARKS | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4802728004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QR0206X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography |
ID Information
| ID | Type | State | Issuer | Description | 585681 | 05 | AZ | MEDICAID |