Basic Information
| Provider Information | |||||||||
| NPI: | 1316952195 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INLAND EMPIRE CARDIOLOGY FACULTY MEDICAL ASSOCIATION INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1579 | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923541579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514865700 | ||||||||
| FaxNumber: | 9514865705 | ||||||||
| Practice Location | |||||||||
| Address1: | 26520 CACTUS AVE | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925553927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514865700 | ||||||||
| FaxNumber: | 9514865705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 12/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | KRISHNAN | ||||||||
| AuthorizedOfficialFirstName: | RAJAGOPAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9514865700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | A48568 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | GR0094510 | 05 | CA | MEDICAID |