Provider Demographics
NPI:1235301466
Name:THE DESERT SPORTS MEDICINE AND SHOULDER CLINIC LLC
Entity Type:Organization
Organization Name:THE DESERT SPORTS MEDICINE AND SHOULDER CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-807-3554
Mailing Address - Street 1:6130 EAST BROWN ROAD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-4960
Mailing Address - Country:US
Mailing Address - Phone:480-807-3554
Mailing Address - Fax:480-807-8330
Practice Address - Street 1:6130 E BROWN RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4960
Practice Address - Country:US
Practice Address - Phone:480-807-3554
Practice Address - Fax:480-807-8330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31646207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ121942Medicare PIN