Basic Information
| Provider Information | |||||||||
| NPI: | 1407823610 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SCOTTSDALE MEDICAL IMAGING, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9700 N 91ST ST STE C200 | ||||||||
| Address2: | SCOTTSDALE MEDICAL IMAGING, LTD. | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852585064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804255000 | ||||||||
| FaxNumber: | 4804255010 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 N SCOTTSDALE RD | ||||||||
| Address2: | #130 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852515648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804255000 | ||||||||
| FaxNumber: | 4804255010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 09/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | OWEN | ||||||||
| AuthorizedOfficialFirstName: | RODNEY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4804255000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0204X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 453621 | 05 | AZ | MEDICAID |