Healthcare Provider Details

I. General information

NPI: 1316206048
Provider Name (Legal Business Name): ONE SOURCE RADIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2076 E UNIVERSITY DR
TEMPE AZ
85281-4632
US

IV. Provider business mailing address

2076 E UNIVERSITY DR
TEMPE AZ
85281-4632
US

V. Phone/Fax

Practice location:
  • Phone: 480-656-5400
  • Fax: 480-656-5408
Mailing address:
  • Phone: 480-656-5400
  • Fax: 480-656-5408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateAZ

VIII. Authorized Official

Name: MR. ADRIAN CARREON
Title or Position: PRESIDENT
Credential:
Phone: 480-399-1742