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NPI Code Detail

MEDICARE: MIRAGE MEDICAL GROUP

MEDICARE: MIRAGE MEDICAL GROUP
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
1174400000XSpecialistA51307CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1A51307OTHERCALICENSE

General Provider Information

NPI Number : 1528208758
Entity Type Code : Organization
Provider Name (Legal Business Name) : MIRAGE MEDICAL GROUP
Provider Business Mailing Address
First Line : 44650 VILLAGE CT STE 100
Second Line :
City : PALM DESERT
State : CA
Zip : 92260-3812
Country : US
Telephone Number : 760-346-4003
Fax Number :
Provider Business Practice Location Address
First Line : 69844 HIGHWAY 111 STE K
Second Line : ONE HAWKEYE PARK
City : RANCHO MIRAGE
State : CA
Zip : 92270-2849
Country : US
Telephone Number : 760-770-4166
Fax Number :
Authorized Official
Title or Position : DIRECTOR OF OPERATIONS
Name : MR. ZORAN RUBAKOVICH
Credential :
Telephone Number : 760-346-4003
Provider Enumeration Date : 02/27/2009
Last Update Date : 02/27/2009

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Directions to “MIRAGE MEDICAL GROUP ” Practice Location

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