Basic Information
| Provider Information | |||||||||
| NPI: | 1962590851 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DESERT VALLEY RADIOLOGY, PLC | ||||||||
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| OtherOrganizationName: | DESERT VALLEY RADIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4045 E. BELL RD. | ||||||||
| Address2: | STE. 143 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850322245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028670404 | ||||||||
| FaxNumber: | 6027880893 | ||||||||
| Practice Location | |||||||||
| Address1: | 2225 W. PEORIA AVE. | ||||||||
| Address2: | STE. 150 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850294938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023955089 | ||||||||
| FaxNumber: | 6023953335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 03/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | WALL III | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6028670404 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 333218 | 05 | AZ | MEDICAID |