MEDICARE: PORTABLE IMAGING OF ARIZONA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0208X	Mobile Radiology Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	389820	OTHER		HEALTHCHOICE
3	389820	OTHER	AZ	AHCCES

General Provider Information

NPI Number	:	1215187570
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTABLE IMAGING OF ARIZONA, LLC

Provider Business Mailing Address
First Line	:	5538 DUNCAN DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-2812
Country	:	US
Telephone Number	:	702-939-6559
Fax Number	:	702-939-6570

Provider Business Practice Location Address
First Line	:	2338 W ROYAL PALM RD
Second Line	:	SUITE A
City	:	PHOENIX
State	:	AZ
Zip	:	85021-9339
Country	:	US
Telephone Number	:	602-864-3656
Fax Number	:	602-864-3660

Authorized Official
Title or Position	:	CFO
Name	:	ABBY GROSSA
Credential	:
Telephone Number	:	702-939-6559

Provider Enumeration Date	:	09/23/2008
Last Update Date	:	03/12/2009

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