Basic Information
Provider Information | |||||||||
NPI: | 1578714028 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EISENHOWER MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EISENHOWER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 39000 BOB HOPE DRIVE | ||||||||
Address2: |   | ||||||||
City: | RANCHO MIRAGE | ||||||||
State: | CA | ||||||||
PostalCode: | 922703221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7603403911 | ||||||||
FaxNumber: | 7606743629 | ||||||||
Practice Location | |||||||||
Address1: | 74785 US HIGHWAY 111 | ||||||||
Address2: | SUITE 100 | ||||||||
City: | INDIAN WELLS | ||||||||
State: | CA | ||||||||
PostalCode: | 922107128 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7608378953 | ||||||||
FaxNumber: | 7608378954 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2008 | ||||||||
LastUpdateDate: | 02/10/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SERFLING | ||||||||
AuthorizedOfficialFirstName: | G | ||||||||
AuthorizedOfficialMiddleName: | AUBREY | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7603403911 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | EISENHOWER MEDICAL CENTER | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 250000142 | CA | N |   | Hospitals | General Acute Care Hospital |   | 261QU0200X | 250000142 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.