Basic Information
| Provider Information | |||||||||
| NPI: | 1124079868 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALM DESERT RADIOLOGY MEDICAL GROUP, INC | ||||||||
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| OtherOrganizationName: | EISENHOWER RADIOLOGY MEDICAL GROUP, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18977 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895110550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7752833315 | ||||||||
| FaxNumber: | 7758526902 | ||||||||
| Practice Location | |||||||||
| Address1: | 39000 BOB HOPE DR | ||||||||
| Address2: | |||||||||
| City: | RANCHO MIRAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608378449 | ||||||||
| FaxNumber: | 7606743852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 06/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | ELLY | ||||||||
| AuthorizedOfficialFirstName: | MEHRAN | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7608378449 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0012730 | 05 | CA | MEDICAID | ZZZ40340Z | 01 | CA | BLUE SHIELD OF CA | OTHER | 1124079868 | 05 | CA | MEDICAID | CC9030 | 01 | CA | RR MEDICARE | OTHER |