Provider Demographics
NPI:1316119605
Name:SOUTHERN DESERT INTERNAL MEDICINE PC
Entity type:Organization
Organization Name:SOUTHERN DESERT INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:TINGEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-730-5100
Mailing Address - Street 1:2600 E SOUTHERN AVE
Mailing Address - Street 2:SUITE B2
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7610
Mailing Address - Country:US
Mailing Address - Phone:480-730-5100
Mailing Address - Fax:480-730-6613
Practice Address - Street 1:2600 E SOUTHERN AVE
Practice Address - Street 2:SUITE B2
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7610
Practice Address - Country:US
Practice Address - Phone:480-730-5100
Practice Address - Fax:480-730-6613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1947363LF0000X
AZ23746207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ120943Medicare PIN