Basic Information
| Provider Information | |||||||||
| NPI: | 1932277183 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEONATOLOGY MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIALTO PEDIATRICS | ||||||||
| 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: | 1786 NORTH RIVERSIDE AVE | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | RIALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923762905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098747660 | ||||||||
| FaxNumber: | 9098749069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MURALIGOPAL | ||||||||
| AuthorizedOfficialFirstName: | VELLORE | ||||||||
| AuthorizedOfficialMiddleName: | GANESH | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9097905071 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| 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 | 0609044 | 01 | CA | CITY OF RIALTO | OTHER |