Basic Information
| Provider Information | |||||||||
| NPI: | 1174760953 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INLAND HEALTHCARE GROUP A MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10488 | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924230488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883449111 | ||||||||
| FaxNumber: | 9093357130 | ||||||||
| Practice Location | |||||||||
| Address1: | 17051 SIERRA LAKES PKWY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923361274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094282040 | ||||||||
| FaxNumber: | 9094282191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2009 | ||||||||
| LastUpdateDate: | 05/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | PAUL | ||||||||
| AuthorizedOfficialFirstName: | CAREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9093357171 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INLAND HEALTHCARE GROUP A MEDICAL CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1366516478 | 05 | CA | MEDICAID | 1174760953 | 05 | CA | MEDICAID | 1629231147 | 05 | CA | MEDICAID | 1265642052 | 05 | CA | MEDICAID | 1871543850 | 05 | CA | MEDICAID | 1508052010 | 05 | CA | MEDICAID |