1265813125 NPI number — TOBIAS MOELLER-BERTRAM, MD CORPORATION DESERT CLINIC PAIN INSTITUTE

Table of content: (NPI 1265813125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265813125 NPI number — TOBIAS MOELLER-BERTRAM, MD CORPORATION DESERT CLINIC PAIN INSTITUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOBIAS MOELLER-BERTRAM, MD CORPORATION DESERT CLINIC PAIN INSTITUTE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
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Provider Other Name Prefix Text:
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NPI Number Information

NPI Number:
1265813125
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3857 BIRCH ST 605
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-783-3600
Provider Business Mailing Address Fax Number:
949-783-3602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36101 BOB HOPE DR STE B-2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RANCHO MIRAGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-321-1315
Provider Business Practice Location Address Fax Number:
760-321-1094
Provider Enumeration Date:
06/16/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MCDONALD
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
949-783-3600

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X , with the licence number:  A80383 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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