Basic Information
| Provider Information | |||||||||
| NPI: | 1841243037 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DESERT VALLEY RADIOLOGY, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4045 E BELL RD | ||||||||
| Address2: | STE. #143 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850322236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028670404 | ||||||||
| FaxNumber: | 6027880893 | ||||||||
| Practice Location | |||||||||
| Address1: | 4045 E BELL RD | ||||||||
| Address2: | STE. #143 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850322236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028670404 | ||||||||
| FaxNumber: | 6027880893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 10/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | RYDER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6028670404 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D., | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1Z7050 | 01 | HEALTHNET | OTHER | AZ0266130 | 01 | AZ | BLUD CROSS BLUE SHIELD | OTHER |