Provider Demographics
NPI:1477683951
Name:HI-DESERT MEDICAL CENTER
Entity Type:Organization
Organization Name:HI-DESERT MEDICAL CENTER
Other - Org Name:HI DESERT RADIOLOGY PHYSICIAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DUDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-366-6421
Mailing Address - Street 1:43500 RIDGE PARK DR
Mailing Address - Street 2:#102
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-3624
Mailing Address - Country:US
Mailing Address - Phone:951-699-0303
Mailing Address - Fax:951-699-0603
Practice Address - Street 1:6601 WHITE FEATHER RD
Practice Address - Street 2:
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252-6607
Practice Address - Country:US
Practice Address - Phone:760-366-6355
Practice Address - Fax:760-366-6364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000231261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ35026ZOtherBLUE SHIELD
CAFNP31524OtherMEDICAL BOARD FICTITIOUS
CAGR0095320Medicaid
CAGR0095320Medicaid