Organization
DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Active
Other names
Salt River Professional Services
Organization subpart
No
Provider details
NPI number
Authorized official
LAURA A TILLMAN MD (CMO)
(602) 263-1674
Entity
Organization
Contact information
Practice address
10005 E OSBORN RD, SCOTTSDALE, AZ 85256-4019
(602) 263-1200
(602) 263-1618
Mailing address
PO BOX 95460, CLEVELAND, OH 44101-0033
(602) 581-6088
(602) 263-1619
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
—
—
207R00000X
Internal Medicine Physician
Primary
—
—
207RE0101X
Endocrinology, Diabetes & Metabolism Physician
—
—
207RN0300X
Nephrology Physician
—
—
208000000X
Pediatrics Physician
—
—
363LF0000X
Family Nurse Practitioner
—
—
367A00000X
Advanced Practice Midwife
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
092353
—
AZ
01
—
P0109880
BCBSAZ
AZ
Enumeration date
01/23/2007
Last updated
05/26/2021
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