Basic Information
| Provider Information | |||||||||
| NPI: | 1467506451 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HALO MEDICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DESERT MEDICAL IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 841163 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900841163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607768989 | ||||||||
| FaxNumber: | 7607798073 | ||||||||
| Practice Location | |||||||||
| Address1: | 74785 US HIGHWAY 111 | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | INDIAN WELLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922107128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607768989 | ||||||||
| FaxNumber: | 7605010311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 04/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAMMOND | ||||||||
| AuthorizedOfficialFirstName: | CORY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7607768989 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 2085N0700X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 2085R0202X | FNP25453 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ02402Z | 01 | CA | BLUE SHIELD PIN | OTHER | ZZZ02402Z | 01 | CA | BLUE CROSS | OTHER | ZZZ64094Z | 01 | CA | BLUE SHIELD PIN | OTHER | ZZZ64094Z | 01 | CA | BLUE CROSS | OTHER | GR0083072 | 05 | CA | MEDICAID | GR0083073 | 05 | CA | MEDICAID | CK9031 | 01 | CA | RAILROAD MEDICARE | OTHER | ZZZ57290Z | 01 | CA | BLUE SHIELD PIN | OTHER | ZZZ05859Z | 01 | CA | BLUE CROSS | OTHER | ZZZ57290Z | 01 | CA | BLUE CROSS | OTHER | GR0083070 | 05 | CA | MEDICAID | GR0083071 | 05 | CA | MEDICAID | ZZZ05859Z | 01 | CA | BLUE SHIELD PIN | OTHER |