Basic Information
| Provider Information | |||||||||
| NPI: | 1952351074 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEONATOLOGY MEDICAL GROUP, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FONTANA FAMILY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17264 FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923359050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094283900 | ||||||||
| FaxNumber: | 9094283903 | ||||||||
| Practice Location | |||||||||
| Address1: | 17264 FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923359050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094283900 | ||||||||
| FaxNumber: | 9094283903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ESCOBAL | ||||||||
| AuthorizedOfficialFirstName: | FIDES | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9094283900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | A78188 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A296540 | 01 | CA | MEDI-CAL | OTHER |