Basic Information
| Provider Information | |||||||||
| NPI: | 1124299334 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DISTRICT MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DESERT HORIZON PSYCHIATRIC SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2929 E THOMAS RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850168034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024705000 | ||||||||
| FaxNumber: | 6024705064 | ||||||||
| Practice Location | |||||||||
| Address1: | 840 E MCKELLIPS RD | ||||||||
| Address2: | SUITE #110 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852039645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024705520 | ||||||||
| FaxNumber: | 4806490783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2008 | ||||||||
| LastUpdateDate: | 03/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | CORDEIRO | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6024705000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DISTRICT MEDICAL GROUP INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 2084P0804X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.