Basic Information
| Provider Information | |||||||||
| NPI: | 1467647388 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DESERT HARBOR INTERNAL MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5757 W THUNDERBIRD RD | ||||||||
| Address2: | W310 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853064649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025487800 | ||||||||
| FaxNumber: | 6025480006 | ||||||||
| Practice Location | |||||||||
| Address1: | 5757 W. THUNDERBIRD RD | ||||||||
| Address2: | SUITE W310 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853064649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025487800 | ||||||||
| FaxNumber: | 6025480006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2007 | ||||||||
| LastUpdateDate: | 01/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | MORGAN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6025487800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 3010 | AZ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 321480 | 05 | AZ | MEDICAID |