Provider Demographics
NPI:1518124700
Name:DESERT HORIZON MEDICAL GROUP
Entity Type:Organization
Organization Name:DESERT HORIZON MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:520-421-1122
Mailing Address - Street 1:1821 N TREKELL RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85222-1705
Mailing Address - Country:US
Mailing Address - Phone:520-421-1122
Mailing Address - Fax:520-421-0751
Practice Address - Street 1:1501 N GILBERT RD
Practice Address - Street 2:SUITE 207
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2390
Practice Address - Country:US
Practice Address - Phone:520-421-1122
Practice Address - Fax:520-421-0751
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DESERT HORIZON MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZCH1571OtherRAILROAD MEDICARE
AZZ62197Medicare PIN