Basic Information
| Provider Information | |||||||||
| NPI: | 1942364732 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY MEDICAL SERVICES ARIZONA-PRIVATE, LLC | ||||||||
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| OtherOrganizationName: | COMMUNITY MEDICAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8444 N 90TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852584437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022488886 | ||||||||
| FaxNumber: | 6022488999 | ||||||||
| Practice Location | |||||||||
| Address1: | 3825 N 24TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850166512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029557997 | ||||||||
| FaxNumber: | 6029540980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | GAITHER | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4809355755 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | OTC6083 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 363A00000X | OTC6083 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 342717 | 05 | AZ | MEDICAID |