Basic Information
| Provider Information | |||||||||
| NPI: | 1396791901 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOMA LINDA UNIV UROLOGY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE NUMBER 54701 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900744701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095583111 | ||||||||
| FaxNumber: | 9095583905 | ||||||||
| Practice Location | |||||||||
| Address1: | 11370 ANDERSON ST | ||||||||
| Address2: | STE 1100 | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095582830 | ||||||||
| FaxNumber: | 9095583905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RUCKLE | ||||||||
| AuthorizedOfficialFirstName: | HERBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT LLU UROLOGY MEDICAL GROUP | ||||||||
| AuthorizedOfficialTelephone: | 9095582830 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | GR0041730 | 05 | CA | MEDICAID |