Basic Information
| Provider Information | |||||||||
| NPI: | 1649449265 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARONDELET HEALTH NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CARONDELET MEDICAL MALL AT RITA RANCH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2202 N FORBES BLVD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857451412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208727700 | ||||||||
| FaxNumber: | 5208727508 | ||||||||
| Practice Location | |||||||||
| Address1: | 8290 S HOUGHTON ROAD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857479702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208733100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2008 | ||||||||
| LastUpdateDate: | 06/16/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STRAUSS | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EVP/CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5208727790 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | OTC-4226 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | OTC-4226 | 01 | AZ | AZ STATE LICENSE | OTHER |