Provider Demographics
NPI:1699896217
Name:DESERT COLON & RECTAL MEDICAL GROUP,INC.
Entity type:Organization
Organization Name:DESERT COLON & RECTAL MEDICAL GROUP,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:LAST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-346-5551
Mailing Address - Street 1:39000 BOB HOPE DR
Mailing Address - Street 2:KIEWIT BUILDING, SUITE 403
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-346-5551
Mailing Address - Fax:760-779-1960
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:KIEWIT BUILDING, SUITE 403
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-346-5551
Practice Address - Fax:760-779-1960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41157174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA29315Medicare UPIN