Healthcare Provider Details

I. General information

NPI: 1861502841
Provider Name (Legal Business Name): INLAND EMPIRE ANESTHESIA MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE DEPARTMENT OF ANESTHESIA
COLTON CA
92324-1801
US

IV. Provider business mailing address

310 N INDIAN HILL BLVD # 601 INLAND EMPIRE ANESTHESIA MEDICAL GROUP
CLAREMONT CA
91711-4611
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-2440
  • Fax: 909-580-2441
Mailing address:
  • Phone: 909-580-2440
  • Fax: 909-580-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberGR0012030
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberGR0012030
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberGR0012030
License Number StateCA

VIII. Authorized Official

Name: MARK E. COMUNALE
Title or Position: PRESIDENT
Credential: MD
Phone: 909-580-2440