Basic Information
| Provider Information | |||||||||
| NPI: | 1821019472 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RENAISSANCE RADIOLOGY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1902 ROYALTY DR | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096208180 | ||||||||
| FaxNumber: | 9094696741 | ||||||||
| Practice Location | |||||||||
| Address1: | 5470 JEFFERSON AVE | ||||||||
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| City: | CHINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917103517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096208180 | ||||||||
| FaxNumber: | 9094696741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KAUFMAN | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9096208180 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
ID Information
| ID | Type | State | Issuer | Description | GR0008539E | 05 | CA | MEDICAID |