Basic Information
| Provider Information | |||||||||
| NPI: | 1770664286 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDENWALD HOGG | ||||||||
| FirstName: | JANET | ||||||||
| MiddleName: | RUTH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MEDENWALD | ||||||||
| OtherFirstName: | JANET | ||||||||
| OtherMiddleName: | RUTH | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 18555 AVENIDA ESCALERA | ||||||||
| Address2: | |||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925628611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8313468236 | ||||||||
| FaxNumber: | 8314544663 | ||||||||
| Practice Location | |||||||||
| Address1: | STEP UP ON SECOND; 600 N. ARROWHEAD AVE, SUITE 200 | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924011152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099635355 | ||||||||
| FaxNumber: | 9094533205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 05/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | G58422 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | G58422 | 01 | CA | MEDICAL LICENSE # | OTHER | AM1761798 | 01 | CA | DEA # | OTHER | ZZZ91891Z | 01 | CA | MEDICARE GROUP ID# | OTHER | ZZZ91892Z | 01 | CA | MEDICARE GROUP ID# | OTHER | ZZZ92069Z | 01 | CA | MEDICARE GROUP ID# | OTHER | BP973 | 05 | CA | MEDICAID | 00G584220 | 05 | CA | MEDICAID |