Basic Information
| Provider Information | |||||||||
| NPI: | 1649383472 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEONATOLOGY MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | TOTS TO TEENS PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8188 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923751388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097907900 | ||||||||
| FaxNumber: | 9097907058 | ||||||||
| Practice Location | |||||||||
| Address1: | 33353 YUCAIPA BLVD | ||||||||
| Address2: | |||||||||
| City: | YUCAIPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923992018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097907900 | ||||||||
| FaxNumber: | 9097907058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MURALIGOPAL | ||||||||
| AuthorizedOfficialFirstName: | VELLORE | ||||||||
| AuthorizedOfficialMiddleName: | GANESH | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9097905071 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0004462 | 05 | CA | MEDICAID |