Provider Demographics
NPI:1508925439
Name:MIRAGE PAIN AND REHABILITATION ASSOCIATES A MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MIRAGE PAIN AND REHABILITATION ASSOCIATES A MEDICAL GROUP, INC.
Other - Org Name:DESERT PAIN & REHABILITATION ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-341-5550
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270
Mailing Address - Country:US
Mailing Address - Phone:760-341-5550
Mailing Address - Fax:760-341-6050
Practice Address - Street 1:72780 COUNTRY CLUB DR.
Practice Address - Street 2:SUITE C-300
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4150
Practice Address - Country:US
Practice Address - Phone:760-341-5550
Practice Address - Fax:760-341-6050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86192174400000X, 2081H0002X
CA20A77842081H0002X
2081H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI25914Medicare UPIN
CAH95523Medicare UPIN