MEDICARE: VALLEY HEART PHYSICIAN MEDICAL GROUP, 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	207RC0000X	Cardiovascular Disease Physician	A38511	CA
2	207RC0001X	Clinical Cardiac Electrophysiology Physician	A38511	CA
3	207RI0011X	Interventional Cardiology Physician	A38511	CA
4	363LP2300X	Primary Care Nurse Practitioner	NP10511	CA
5	207R00000X	Internal Medicine Physician	A65342	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ52542Z	OTHER	CA	BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730350521
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VALLEY HEART PHYSICIAN MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	58457 29 PALMS HWY STE 200
Second Line	:
City	:	YUCCA VALLEY
State	:	CA
Zip	:	92284-5879
Country	:	US
Telephone Number	:	760-228-1813
Fax Number	:

Provider Business Practice Location Address
First Line	:	58457 29 PALMS HWY STE 200
Second Line	:
City	:	YUCCA VALLEY
State	:	CA
Zip	:	92284-5879
Country	:	US
Telephone Number	:	760-228-1813
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MADHUSUDHAN GUPTA
Credential	:	M.D.
Telephone Number	:	760-228-1813

Provider Enumeration Date	:	03/19/2008
Last Update Date	:	03/19/2008

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