Basic Information
| Provider Information | |||||||||
| NPI: | 1548218134 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHERRY | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2653 W GUADALUPE ROAD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808893500 | ||||||||
| FaxNumber: | 4808893502 | ||||||||
| Practice Location | |||||||||
| Address1: | 4915 E BASELINE RD | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803549200 | ||||||||
| FaxNumber: | 4803549201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 11/20/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | 21626 | AZ | Y | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
ID Information
| ID | Type | State | Issuer | Description | 470001313 | 01 | AZ | RAILROAD MEDICARE | OTHER | AZ0324990 | 01 | AZ | BCBS | OTHER | 1Z7049 | 01 | AZ | HEALTHNET | OTHER | 138140 | 01 | AZ | AHCCCS | OTHER |