Basic Information
| Provider Information | |||||||||
| NPI: | 1134200983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RENAISSANCE RADIOLOGY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8599 HAVEN AVE. | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917304849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096208180 | ||||||||
| FaxNumber: | 9099197288 | ||||||||
| Practice Location | |||||||||
| Address1: | 8599 HAVEN AVE. | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917304849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096208180 | ||||||||
| FaxNumber: | 9099197288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 07/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | KIEF-GARCIA | ||||||||
| AuthorizedOfficialFirstName: | MONIKA | ||||||||
| AuthorizedOfficialMiddleName: | LYNNE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, CEO | ||||||||
| AuthorizedOfficialTelephone: | 9096208180 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | C08660 | 01 | CA | BUSINESS LICENSE | OTHER | GR0085394 | 05 | CA | MEDICAID | GR008539C | 05 | CA | MEDICAID | GR0085392 | 05 | CA | MEDICAID | GR008539K | 05 | CA | MEDICAID | GR008539F | 05 | CA | MEDICAID | GR008539B | 05 | CA | MEDICAID |