Healthcare Provider Details

I. General information

NPI: 1386133080
Provider Name (Legal Business Name): DESERT RIDGE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21001 N TATUM BLVD STE 78-1640
PHOENIX AZ
85050-5244
US

IV. Provider business mailing address

PO BOX 6610
CHANDLER AZ
85246-6610
US

V. Phone/Fax

Practice location:
  • Phone: 480-926-7800
  • Fax: 480-926-2260
Mailing address:
  • Phone: 480-926-7800
  • Fax: 480-926-2260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: ELLIE DESCALZO
Title or Position: CREDENTIALING OFFICER
Credential:
Phone: 480-926-7800