Provider Demographics
NPI:1922590975
Name:DESERT PAIN AND REHAB SPECIALISTS
Entity Type:Organization
Organization Name:DESERT PAIN AND REHAB SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-944-2222
Mailing Address - Street 1:11047 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4816
Mailing Address - Country:US
Mailing Address - Phone:602-944-2222
Mailing Address - Fax:602-331-2499
Practice Address - Street 1:2005 HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-9601
Practice Address - Country:US
Practice Address - Phone:925-425-8273
Practice Address - Fax:928-425-3066
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DESERT PAIN AND REHAB SPECIALISTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-05
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ306932Medicaid