Provider Demographics
NPI:1215048756
Name:DESERT RIDGE GASTROENTEROLOGY
Entity type:Organization
Organization Name:DESERT RIDGE GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:S
Authorized Official - Last Name:SAND
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-585-9555
Mailing Address - Street 1:4045 E BELL RD
Mailing Address - Street 2:#139
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2236
Mailing Address - Country:US
Mailing Address - Phone:602-996-8888
Mailing Address - Fax:
Practice Address - Street 1:4045 E BELL RD
Practice Address - Street 2:#139
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2236
Practice Address - Country:US
Practice Address - Phone:602-996-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ29754Medicare PIN