Basic Information
| Provider Information | |||||||||
| NPI: | 1144423468 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERNAL MEDICINE MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 840 TOWNE CENTER DRIVE | ||||||||
| Address2: | INTERNAL MEDICINE MEDICAL GROUP | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917675900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093981500 | ||||||||
| FaxNumber: | 9093981573 | ||||||||
| Practice Location | |||||||||
| Address1: | 10837 LAUREL AVENUE | ||||||||
| Address2: | INTERNAL MEDICINE MEDICAL GROUP SUITE 104 | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917307643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095816732 | ||||||||
| FaxNumber: | 9095816737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | ADRIENNE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9093981550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
No ID Information.