Basic Information
| Provider Information | |||||||||
| NPI: | 1316140619 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERNAL MEDICINE MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 840 TOWNE CENTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093981550 | ||||||||
| FaxNumber: | 9093981573 | ||||||||
| Practice Location | |||||||||
| Address1: | 1866 N ORANGE GROVE AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098650676 | ||||||||
| FaxNumber: | 9098658483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 10/15/2007 | ||||||||
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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 | 207RC0200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RG0300X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RP1001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0011290 | 05 | CA | MEDICAID |