Basic Information
| Provider Information | |||||||||
| NPI: | 1518136787 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INLAND HEALTHCARE GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10488 | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924230488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883449111 | ||||||||
| FaxNumber: | 9093357130 | ||||||||
| Practice Location | |||||||||
| Address1: | 7430 CHERRY AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923364255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098294680 | ||||||||
| FaxNumber: | 9098540260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2008 | ||||||||
| LastUpdateDate: | 09/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | PERKO | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9093357171 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1518136787 | 05 | CA | MEDICAID | 1871543850 | 05 | CA | MEDICAID |