Basic Information
| Provider Information | |||||||||
| NPI: | 1518011824 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PAGE PRO FEE BILLING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1441 N 12TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062837 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 NORTH NAVAJO | ||||||||
| Address2: | |||||||||
| City: | PAGE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286452424 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 10/22/2007 | ||||||||
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| AuthorizedOfficialLastName: | DAHLEN | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR VICE PRESIDENT FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6027474000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BANNER HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 192639 | 05 | AZ | MEDICAID |