Provider Demographics
NPI:1326493768
Name:DESERT PRINCESS MEDICAL GRP
Entity Type:Organization
Organization Name:DESERT PRINCESS MEDICAL GRP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:HAINES
Authorized Official - Last Name:DEMIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-559-4776
Mailing Address - Street 1:8711 E PINNACLE PEAK RD
Mailing Address - Street 2:BOX 218
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-3517
Mailing Address - Country:US
Mailing Address - Phone:480-559-4776
Mailing Address - Fax:866-526-7086
Practice Address - Street 1:9377 E BELL RD STE 131
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1503
Practice Address - Country:US
Practice Address - Phone:480-559-4776
Practice Address - Fax:866-526-7086
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DESERT PRINCESS MEDICAL GRP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-03
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207VG0400X
AZ36773261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ203537Medicaid