Basic Information
| Provider Information | |||||||||
| NPI: | 1225012644 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RENAISSANCE RADIOLOGY MED GRP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1902 ROYALTY DRIVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096208180 | ||||||||
| FaxNumber: | 9094696741 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 N WATERMAN AVE | ||||||||
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| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924044836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096208180 | ||||||||
| FaxNumber: | 9094696741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 06/24/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/28/2007 | ||||||||
| NPIReactivationDate: | 10/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | KIEF GARCIA | ||||||||
| AuthorizedOfficialFirstName: | MONIKA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 9096208180 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR008539F | 05 | CA | MEDICAID | CG1263 | 01 | CA | RAILROAD MEDICARE | OTHER |