Provider Demographics
NPI:1427335140
Name:DHHS IHS PHOENIX AREA
Entity type:Organization
Organization Name:DHHS IHS PHOENIX AREA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:928-338-4911
Mailing Address - Street 1:200 WEST HOSPITAL DRIVE
Mailing Address - Street 2:P.O. BOX 860
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941-0860
Mailing Address - Country:US
Mailing Address - Phone:928-338-4911
Mailing Address - Fax:928-338-5508
Practice Address - Street 1:200 WEST HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941-0860
Practice Address - Country:US
Practice Address - Phone:928-338-4911
Practice Address - Fax:928-338-5508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-09
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ092403OtherMEDICAID DENTAL
AZ020561Medicaid
030113Medicare Oscar/Certification
HSZ241Medicare PIN
AZ092403OtherMEDICAID DENTAL