Basic Information
Provider Information
NPI: 1225055239
EntityType: 2
ReplacementNPI:  
OrganizationName: RANCHO MIRAGE ANESTHESIA CONSULTANTS MEDICAL GROUP INC
LastName:  
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Mailing Information
Address1: PO BOX 60790
Address2:  
City: PASADENA
State: CA
PostalCode: 911166790
CountryCode: US
TelephoneNumber: 6267956596
FaxNumber: 6267958247
Practice Location
Address1: 39000 BOB HOPE DR
Address2:  
City: RANCHO MIRAGE
State: CA
PostalCode: 922703221
CountryCode: US
TelephoneNumber: 7603403911
FaxNumber: 7607731497
Other Information
ProviderEnumerationDate: 07/16/2006
LastUpdateDate: 11/10/2009
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: NELSON
AuthorizedOfficialFirstName: DANIEL
AuthorizedOfficialMiddleName: HOWARD
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 6267956596
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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AuthorizedOfficialCredential: M.D.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207L00000X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansAnesthesiology 

ID Information
IDTypeStateIssuerDescription
GR002841005CA MEDICAID
ZZZ16551Z01CABLUE SHIELDOTHER


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