Basic Information
| Provider Information | |||||||||
| NPI: | 1285768390 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAGELLAN HEALTH SERVICES OF ARIZONA, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MARICOPA CLINIC WEST VALLEY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4129 EAST VAN BUREN STREET | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005645465 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11361 N 99TH AVE | ||||||||
| Address2: | #601 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853455470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026853846 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 10/15/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARSON | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | ADAIR | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6027978333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | BH1290 | AZ | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 535510 | 05 | AZ | MEDICAID |