MEDICARE: DESERT MEDICAL IMAGING, A MEDICAL CORPORATION

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	2085R0202X	Diagnostic Radiology Physician	FNP25453	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	ZZZ02402Z	OTHER	CA	BLUE CROSS GROUP NUMBER

General Provider Information

NPI Number	:	1083614929
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESERT MEDICAL IMAGING, A MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	74785 US HIGHWAY 111
Second Line	:	STE 101
City	:	INDIAN WELLS
State	:	CA
Zip	:	92210-7128
Country	:	US
Telephone Number	:	760-776-8989
Fax Number	:	760-779-8073

Provider Business Practice Location Address
First Line	:	1133 N PALM CANYON DR
Second Line	:	STE B
City	:	PALM SPRINGS
State	:	CA
Zip	:	92262-4401
Country	:	US
Telephone Number	:	760-322-8883
Fax Number	:	760-325-2037

Authorized Official
Title or Position	:	CFO
Name	:	CORY HAMMOND
Credential	:
Telephone Number	:	760-776-8989

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	04/03/2019

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