Provider Demographics
NPI:1720196702
Name:HIGH DESERT MEDICAL GROUP
Entity Type:Organization
Organization Name:HIGH DESERT MEDICAL GROUP
Other - Org Name:HIGH DESERT MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MYAING
Authorized Official - Last Name:LIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-945-5984
Mailing Address - Street 1:PO BOX 7007
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93539-7007
Mailing Address - Country:US
Mailing Address - Phone:661-945-5984
Mailing Address - Fax:661-951-3192
Practice Address - Street 1:43839 15TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4756
Practice Address - Country:US
Practice Address - Phone:661-945-5984
Practice Address - Fax:661-951-3192
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE PROVIDER NETWORK, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-29
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0047931Medicaid
CAGR0047930Medicaid
CAGR0047930Medicaid