Healthcare Provider Details

I. General information

NPI: 1295061422
Provider Name (Legal Business Name): PUEBLO RADIOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2009
Last Update Date: 10/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 W SAINT MARYS RD
TUCSON AZ
85745-3112
US

IV. Provider business mailing address

PO BOX 1810
SCOTTSDALE AZ
85252-1810
US

V. Phone/Fax

Practice location:
  • Phone: 520-352-7600
  • Fax: 520-352-7610
Mailing address:
  • Phone: 520-352-7600
  • Fax: 520-352-7610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL ALAN DERHAAG
Title or Position: MANAGER
Credential:
Phone: 520-352-7600