Provider Demographics
NPI:1467509372
Name:DESERT PALMS MEDICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:DESERT PALMS MEDICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BRENNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-763-2001
Mailing Address - Street 1:3015 HIGHWAY 95 STE 105
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-4334
Mailing Address - Country:US
Mailing Address - Phone:928-763-2001
Mailing Address - Fax:928-763-2038
Practice Address - Street 1:3015 HIGHWAY 95 STE 105
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-4334
Practice Address - Country:US
Practice Address - Phone:928-763-2001
Practice Address - Fax:928-763-2038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23472207R00000X
261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ323171Medicaid