Basic Information
| Provider Information | |||||||||
| NPI: | 1104014257 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIERRA VISTA DIAGNOSTICS LLC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 155 CALLE PORTAL STE 500 | ||||||||
| Address2: | |||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856352973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204595227 | ||||||||
| FaxNumber: | 5204592191 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 CALLE PORTAL STE 500 | ||||||||
| Address2: | |||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856352973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204595227 | ||||||||
| FaxNumber: | 5204592191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2007 | ||||||||
| LastUpdateDate: | 12/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | WALSH | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | I. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5204595227 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 9110 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 255085001 | 05 | AZ | MEDICAID | DD8752 | 01 | AZ | RAILROAD MEDICARE | OTHER | 220575001 | 05 | AZ | MEDICAID |