Basic Information
| Provider Information | |||||||||
| NPI: | 1851404693 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEONATOLOGY MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | FONTANA FAMILY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8188 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923751388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097905071 | ||||||||
| FaxNumber: | 9097905774 | ||||||||
| Practice Location | |||||||||
| Address1: | 17264 FOOTHILL BLVD | ||||||||
| Address2: | STE A B | ||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923359051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094283900 | ||||||||
| FaxNumber: | 9094283903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 08/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | MURALIGOPAL | ||||||||
| AuthorizedOfficialFirstName: | GRACE | ||||||||
| AuthorizedOfficialMiddleName: | ESCOBAL | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9097905071 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 2080N0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 207QA0505X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0004461 | 05 | CA | MEDICAID |