Healthcare Provider Details

I. General information

NPI: 1558026880
Provider Name (Legal Business Name): ARCHWELL HEALTH PROFESSIONAL SERVICES OF ARIZONA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 E MAIN ST
MESA AZ
85205-8605
US

IV. Provider business mailing address

102 WOODMONT BLVD STE 600
NASHVILLE TN
37205-5250
US

V. Phone/Fax

Practice location:
  • Phone: 480-870-7500
  • Fax: 480-906-2173
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: AMY MODDESETTE
Title or Position: SR. DIRECTOR, MANAGED CARE OPS
Credential:
Phone: 629-224-1614