Basic Information
| Provider Information | |||||||||
| NPI: | 1083614929 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DESERT MEDICAL IMAGING, A MEDICAL CORPORATION | ||||||||
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| OtherOrganizationName: | DESERT MEDICAL IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 74785 US HIGHWAY 111 | ||||||||
| Address2: | STE 101 | ||||||||
| City: | INDIAN WELLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922107128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607768989 | ||||||||
| FaxNumber: | 7607798073 | ||||||||
| Practice Location | |||||||||
| Address1: | 1133 N PALM CANYON DR | ||||||||
| Address2: | STE B | ||||||||
| City: | PALM SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922624401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603228883 | ||||||||
| FaxNumber: | 7603252037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 04/03/2019 | ||||||||
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| AuthorizedOfficialLastName: | HAMMOND | ||||||||
| AuthorizedOfficialFirstName: | CORY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7607768989 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | FNP25453 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0083071 | 05 | CA | MEDICAID | ZZZ02402Z | 01 | CA | BLUE CROSS GROUP NUMBER | OTHER |