Basic Information
| Provider Information | |||||||||
| NPI: | 1437173804 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HIGH DESERT HEART INSTITUTE MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12780 HESPERIA RD | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923955806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602412270 | ||||||||
| FaxNumber: | 7602414081 | ||||||||
| Practice Location | |||||||||
| Address1: | 12780 HESPERIA RD | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923955806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602412270 | ||||||||
| FaxNumber: | 7602414081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 07/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | ARUNASALAM | ||||||||
| AuthorizedOfficialFirstName: | SIVA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7609465177 | ||||||||
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| 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 | 207UN0901X | G66022 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 2085N0904X | G66022 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 207RC0000X | G66022 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1437173804 | 05 | CA | MEDICAID |