Basic Information
| Provider Information | |||||||||
| NPI: | 1487618013 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAMELBACK IMAGING HOLDINGS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 98341 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850380341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029439200 | ||||||||
| FaxNumber: | 6022163000 | ||||||||
| Practice Location | |||||||||
| Address1: | 15215 S 48TH ST | ||||||||
| Address2: | BUILDING 1 SUITE 110 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850449142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809409729 | ||||||||
| FaxNumber: | 4809409730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 10/10/2007 | ||||||||
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| AuthorizedOfficialLastName: | COHEN | ||||||||
| AuthorizedOfficialFirstName: | JORDAN | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6029439200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 850950 | 05 | AZ | MEDICAID |