1528208758 NPI number — MIRAGE MEDICAL GROUP

Table of content: (NPI 1528208758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528208758 NPI number — MIRAGE MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIRAGE MEDICAL GROUP
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:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528208758
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44650 VILLAGE CT STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM DESERT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92260-3812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-346-4003
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
69844 HIGHWAY 111 STE K
Provider Second Line Business Practice Location Address:
ONE HAWKEYE PARK
Provider Business Practice Location Address City Name:
RANCHO MIRAGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92270-2849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-770-4166
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
RUBAKOVICH
Authorized Official First Name:
ZORAN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
760-346-4003

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  A51307 , 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)

  • Identifier: A51307 . This is a "LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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