MEDICARE: PHOENIX DIAGNOSTIC IMAGING INC

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	2085R0202X	Diagnostic Radiology Physician		AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00156014	OTHER	AZ	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1316922420
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX DIAGNOSTIC IMAGING INC

Provider Business Mailing Address
First Line	:	PO BOX 52527
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85072-2527
Country	:	US
Telephone Number	:	480-545-0113
Fax Number	:	480-545-4267

Provider Business Practice Location Address
First Line	:	6320 W UNION HILLS DR
Second Line	:	BUILDING A, SUITE 110
City	:	GLENDALE
State	:	AZ
Zip	:	85308-1096
Country	:	US
Telephone Number	:	623-939-9919
Fax Number	:	623-537-0229

Authorized Official
Title or Position	:	COO
Name	:	MR. DANIEL J SC HAEFER
Credential	:
Telephone Number	:	770-300-0101

Provider Enumeration Date	:	12/12/2005
Last Update Date	:	06/21/2010

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