Provider Demographics
NPI:1124079868
Name:PALM DESERT RADIOLOGY MEDICAL GROUP, INC
Entity type:Organization
Organization Name:PALM DESERT RADIOLOGY MEDICAL GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MEHRAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:ELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-837-8449
Mailing Address - Street 1:PO BOX 1629
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-0030
Mailing Address - Country:US
Mailing Address - Phone:760-837-8449
Mailing Address - Fax:760-773-1848
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270
Practice Address - Country:US
Practice Address - Phone:760-837-8449
Practice Address - Fax:775-624-9774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124079868Medicaid
CACC9030OtherRR MEDICARE
CAGR0012730Medicaid
CAZZZ40340ZOtherBLUE SHIELD OF CA