Basic Information
Provider Information | |||||||||
NPI: | 1750405064 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MAGELLAN HEALTH SERVICES OF ARIZONA, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MARICOPA CLINIC WEST CAMELBACK | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4129 EAST VAN BUREN STREET | ||||||||
Address2: | SUITE 150 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 85008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8005645465 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5022 N 54TH AVE | ||||||||
Address2: | #4 | ||||||||
City: | GLENDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853017531 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6239314343 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/19/2007 | ||||||||
LastUpdateDate: | 10/15/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CARSON | ||||||||
AuthorizedOfficialFirstName: | CHRIS | ||||||||
AuthorizedOfficialMiddleName: | ADAIR | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6027978333 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | BH592 | AZ | Y |   | Agencies | Case Management |   |
ID Information
ID | Type | State | Issuer | Description | 532053 | 05 | AZ |   | MEDICAID |