Healthcare Provider Details

I. General information

NPI: 1679628531
Provider Name (Legal Business Name): DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10005 E OSBORN RD
SCOTTSDALE AZ
85256-4019
US

IV. Provider business mailing address

PO BOX 95460
CLEVELAND OH
44101-0033
US

V. Phone/Fax

Practice location:
  • Phone: 602-263-1200
  • Fax: 602-263-1618
Mailing address:
  • Phone: 602-581-6088
  • Fax: 602-263-1619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LAURA A TILLMAN
Title or Position: CMO
Credential: MD
Phone: 602-263-1674