Basic Information
Provider Information | |||||||||
NPI: | 1164625588 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INTERNAL MEDICINE MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 840 TOWNE CENTER DRIVE | ||||||||
Address2: | INTERNAL MEDICINE MEDICAL GROUP | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917675900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9093981550 | ||||||||
FaxNumber: | 9093981573 | ||||||||
Practice Location | |||||||||
Address1: | 16465 SIERRA LAKES PARKWAY | ||||||||
Address2: | INTERNAL MEDICINE MEDICAL GROUP SUITE | ||||||||
City: | FONTANA | ||||||||
State: | CA | ||||||||
PostalCode: | 923361242 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9097708640 | ||||||||
FaxNumber: | 9097708650 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WALKER | ||||||||
AuthorizedOfficialFirstName: | ADRIENNE | ||||||||
AuthorizedOfficialMiddleName: | MARIE | ||||||||
AuthorizedOfficialTitleorPosition: | CONTRACTS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 9093981550 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 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.