Provider Demographics
NPI:1982735031
Name:DESERT HORIZON MEDICAL GROUP
Entity Type:Organization
Organization Name:DESERT HORIZON MEDICAL GROUP
Other - Org Name:DESERT HORIZON INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-421-1122
Mailing Address - Street 1:PO BOX 13410
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-0041
Mailing Address - Country:US
Mailing Address - Phone:520-421-1122
Mailing Address - Fax:520-421-0751
Practice Address - Street 1:2501 E SOUTHERN AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7669
Practice Address - Country:US
Practice Address - Phone:520-421-1122
Practice Address - Fax:520-421-0751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ62197Medicare PIN