Basic Information
| Provider Information | |||||||||
| NPI: | 1740450923 | ||||||||
| 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: | 8883449111 | ||||||||
| FaxNumber: | 9093357130 | ||||||||
| Practice Location | |||||||||
| Address1: | 1850 N RIVERSIDE AVE | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | RIALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923768071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095620255 | ||||||||
| FaxNumber: | 9094213034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2008 | ||||||||
| 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 | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1992755284 | 05 | CA | MEDICAID | 1740450923 | 05 | CA | MEDICAID |