Basic Information
| Provider Information | |||||||||
| NPI: | 1598872657 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORONA ORTHOPAEDIC ASSOCIATES MEDICAL GROUP INCORPORATED | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CORONA-TEMECULA ORTHOPAEDIC ASSOCIATES MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 341 MAGNOLIA AVENUE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928793331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517356060 | ||||||||
| FaxNumber: | 9517354510 | ||||||||
| Practice Location | |||||||||
| Address1: | 341 MAGNOLIA AVENUE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928793331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517356060 | ||||||||
| FaxNumber: | 9517354510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 10/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | BAUM | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | LLOYD | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9517356060 | ||||||||
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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 | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | GR0070300 | 05 | CA | MEDICAID | 925392B | 05 | CA | MEDICAID | ZZZ51830Z | 01 | BLUE SHIELD OF CALIFORNIA | OTHER | CI7854 | 01 | RAIL ROAD MEDICARE | OTHER |