1457312175 NPI number — INLAND EMPIRE UROLOGY MEDICAL GROUP INC

Table of content: (NPI 1457312175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457312175 NPI number — INLAND EMPIRE UROLOGY MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INLAND EMPIRE UROLOGY MEDICAL GROUP INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457312175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4500 BROCKTON AVE
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92501-4090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-683-7620
Provider Business Mailing Address Fax Number:
951-683-3052

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4500 BROCKTON AVE
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92501-4090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-683-7620
Provider Business Practice Location Address Fax Number:
951-683-3052
Provider Enumeration Date:
03/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PIETRO
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
M.D.
Authorized Official Telephone Number:
951-683-7620

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  A43577 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com