Basic Information
| Provider Information | |||||||||
| NPI: | 1811996747 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DESERT MEDICAL IMAGING, A MEDICAL CORPORATION | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DESERT MEDICAL IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 74785 US HIGHWAY 111 | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | INDIAN WELLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922107128 | ||||||||
| 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: | 7607798073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 04/03/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAMMOND | ||||||||
| AuthorizedOfficialFirstName: | CORY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7607768989 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | FNP25453 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0083070 | 05 | CA | MEDICAID | ZZZ57290Z | 01 | CA | BLUE CROSS GROUP ID | OTHER |