MEDICARE: ARIZONA STATE UNIVERSITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center		AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z21383	OTHER	AZ	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144387978
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARIZONA STATE UNIVERSITY

Provider Business Mailing Address
First Line	:	500 N 3RD ST
Second Line	:	SUITE 155
City	:	PHOENIX
State	:	AZ
Zip	:	85004-2135
Country	:	US
Telephone Number	:	602-496-0721
Fax Number	:	602-496-0675

Provider Business Practice Location Address
First Line	:	500 N 3RD ST
Second Line	:	SUITE 155
City	:	PHOENIX
State	:	AZ
Zip	:	85004-2135
Country	:	US
Telephone Number	:	602-496-0721
Fax Number	:	602-496-0675

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DIANE L PERRY
Credential	:	RNP
Telephone Number	:	602-496-0665

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	05/15/2013

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Directions to “ARIZONA STATE UNIVERSITY ” Practice Location

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