Provider Demographics
NPI:1699091934
Name:PUEBLO RADIOLOGY, LLC
Entity type:Organization
Organization Name:PUEBLO RADIOLOGY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:DERHAAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-973-9800
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85252-1810
Mailing Address - Country:US
Mailing Address - Phone:602-973-9800
Mailing Address - Fax:602-973-9933
Practice Address - Street 1:5501 N 19TH AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2450
Practice Address - Country:US
Practice Address - Phone:602-973-9800
Practice Address - Fax:602-973-9933
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN ARIZONA RADIOLOGY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ863979Medicaid
AZZ79512Medicare UPIN