Basic Information
| Provider Information | |||||||||
| NPI: | 1831184191 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DRUMMOND MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | INDIAN WELLS VALLEY SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 N. CHINA LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | RIDGECREST | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935553131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604468100 | ||||||||
| FaxNumber: | 7604468181 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 N. CHINA LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | RIDGECREST | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935553131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604468100 | ||||||||
| FaxNumber: | 7604468181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 05/19/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | D | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7604468201 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 120000489 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | SUR01373F | 05 | CA | MEDICAID | 05-C0001373 | 01 | CMS CERTIFICATION NUMBER | OTHER |