Basic Information
| Provider Information | |||||||||
| NPI: | 1528238961 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INLAND HEALTHCARE GROUP, A MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10488 | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924230488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093357171 | ||||||||
| FaxNumber: | 9093357139 | ||||||||
| Practice Location | |||||||||
| Address1: | 2150 N WATERMAN AVE | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924044811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098864971 | ||||||||
| FaxNumber: | 9098830459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/29/2008 | ||||||||
| LastUpdateDate: | 05/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | PAUL | ||||||||
| AuthorizedOfficialFirstName: | CAREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9093357171 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INLAND HEALTHCARE GROUP, A MEDICAL CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1235351206 | 05 | CA | MEDICAID | 1528238961 | 05 | CA | MEDICAID | 1497965529 | 05 | CA | MEDICAID | ZZZ70178Z | 01 | CA | BS/TRIWEST | OTHER |