Provider Demographics
NPI:1487645933
Name:DESERT MEDICAL GROUP-DESERT SPECIALTY GROUP
Entity type:Organization
Organization Name:DESERT MEDICAL GROUP-DESERT SPECIALTY GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HELENE
Authorized Official - Middle Name:
Authorized Official - Last Name:LECLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-320-4122
Mailing Address - Street 1:275 N EL CIELO RD
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-6972
Mailing Address - Country:US
Mailing Address - Phone:760-320-4122
Mailing Address - Fax:760-320-2725
Practice Address - Street 1:69844 HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-2849
Practice Address - Country:US
Practice Address - Phone:760-318-4869
Practice Address - Fax:760-320-2725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ00919ZMedicare ID - Type Unspecified