MEDICARE: DESERT FOUNTAIN MEDICAL INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1558863886
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESERT FOUNTAIN MEDICAL INC

Provider Business Mailing Address
First Line	:	17100 E SHEA BLVD STE 320
Second Line	:
City	:	FOUNTAIN HILLS
State	:	AZ
Zip	:	85268-6654
Country	:	US
Telephone Number	:	480-816-8300
Fax Number	:	480-816-4016

Provider Business Practice Location Address
First Line	:	17100 E SHEA BLVD STE 320
Second Line	:
City	:	FOUNTAIN HILLS
State	:	AZ
Zip	:	85268-6654
Country	:	US
Telephone Number	:	480-816-8300
Fax Number	:	480-816-4016

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	GRANT ANDRES
Credential	:
Telephone Number	:	480-816-8300

Provider Enumeration Date	:	03/02/2018
Last Update Date	:	03/02/2018

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