Basic Information
| Provider Information | |||||||||
| NPI: | 1316997596 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOMA LINDA UNIVERSITY CARDIOLOGY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10427 | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924230427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095588591 | ||||||||
| FaxNumber: | 9095580118 | ||||||||
| Practice Location | |||||||||
| Address1: | 11234 ANDERSON ST | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923542804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095584200 | ||||||||
| FaxNumber: | 9095587975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 08/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | JUTZY | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9095584200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | GR0042260 | 05 | CA | MEDICAID |