Healthcare Provider Details

I. General information

NPI: 1881895498
Provider Name (Legal Business Name): ARIZONA HEART INSTITUTE SCW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13967 W GRAND AVE SUITE 100
SURPRISE AZ
85374-3548
US

IV. Provider business mailing address

PO BOX 61773
PHOENIX AZ
85082-1773
US

V. Phone/Fax

Practice location:
  • Phone: 623-584-0052
  • Fax: 623-584-3706
Mailing address:
  • Phone: 602-682-6727
  • Fax: 602-240-6177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: EDWARD DIETHRICH
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 602-266-2200