Provider Demographics
NPI:1588162911
Name:DESERT EDGE MEDICAL
Entity type:Organization
Organization Name:DESERT EDGE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:BORROWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:435-656-2995
Mailing Address - Street 1:93 W ORCHARD LN
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-2072
Mailing Address - Country:US
Mailing Address - Phone:435-862-5925
Mailing Address - Fax:
Practice Address - Street 1:1664 S DIXIE DR STE D201
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770
Practice Address - Country:US
Practice Address - Phone:435-656-2995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-31
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
UT261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1487001442Medicaid