Healthcare Provider Details

I. General information

NPI: 1851404693
Provider Name (Legal Business Name): NEONATOLOGY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17264 FOOTHILL BLVD STE A B
FONTANA CA
92335-9051
US

IV. Provider business mailing address

PO BOX 8188
REDLANDS CA
92375-1388
US

V. Phone/Fax

Practice location:
  • Phone: 909-428-3900
  • Fax: 909-428-3903
Mailing address:
  • Phone: 909-790-5071
  • Fax: 909-790-5774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. GRACE ESCOBAL MURALIGOPAL
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 909-790-5071