MEDICARE: PUEBLO RADIOLOGY LLC

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	261QR0200X	Radiology Clinic/Center
2	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center

General Provider Information

NPI Number	:	1295061422
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUEBLO RADIOLOGY LLC

Provider Business Mailing Address
First Line	:	PO BOX 1810
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85252-1810
Country	:	US
Telephone Number	:	520-352-7600
Fax Number	:	520-352-7610

Provider Business Practice Location Address
First Line	:	1313 W SAINT MARYS RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85745-3112
Country	:	US
Telephone Number	:	520-352-7600
Fax Number	:	520-352-7610

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. DANIEL ALAN DERHAAG
Credential	:
Telephone Number	:	520-352-7600

Provider Enumeration Date	:	10/22/2009
Last Update Date	:	10/22/2009

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Directions to “PUEBLO RADIOLOGY LLC ” Practice Location

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