Provider Demographics
NPI:1528208758
Name:MIRAGE MEDICAL GROUP
Entity Type:Organization
Organization Name:MIRAGE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:ZORAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBAKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-346-4003
Mailing Address - Street 1:44650 VILLAGE CT STE 100
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-3812
Mailing Address - Country:US
Mailing Address - Phone:760-346-4003
Mailing Address - Fax:
Practice Address - Street 1:69844 HIGHWAY 111 STE K
Practice Address - Street 2:ONE HAWKEYE PARK
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-2849
Practice Address - Country:US
Practice Address - Phone:760-770-4166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-27
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51307174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA51307OtherLICENSE
CA00A513071Medicare PIN
F94592Medicare UPIN