Provider Demographics
NPI:1255796496
Name:MAYO CLINIC ARIZONA
Entity type:Organization
Organization Name:MAYO CLINIC ARIZONA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:
Authorized Official - First Name:ROSHANAK
Authorized Official - Middle Name:
Authorized Official - Last Name:DIDEHBAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-301-6493
Mailing Address - Street 1:PO BOX 083268
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60691-0268
Mailing Address - Country:US
Mailing Address - Phone:507-284-3390
Mailing Address - Fax:
Practice Address - Street 1:5881 E MAYO BLVD
Practice Address - Street 2:# STE 1-304
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054-4505
Practice Address - Country:US
Practice Address - Phone:480-342-4100
Practice Address - Fax:480-342-4180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-15
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0065693336C0002X
3336I0012X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2155895OtherPK
AZ0386430008Medicare NSC