Basic Information
| Provider Information | |||||||||
| NPI: | 1518932110 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MODERN DIAGNOSTIC IMAGING PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 S DOBSON RD | ||||||||
| Address2: | B16 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852245678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804459961 | ||||||||
| FaxNumber: | 4804459972 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 S DOBSON RD | ||||||||
| Address2: | B16 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852245678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804459961 | ||||||||
| FaxNumber: | 4804459972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 03/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | MEHTA | ||||||||
| AuthorizedOfficialFirstName: | SHEETAL | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4804459961 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | AZ0153760 | 01 | AZ | BCBSAZ | OTHER | 181760 | 05 | AZ | MEDICAID | 2Z2341 | 01 | AZ | HEALTH NET OF ARIZONA | OTHER |