Healthcare Provider Details

I. General information

NPI: 1386724433
Provider Name (Legal Business Name): INTERNAL MEDICINE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 10/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1866 N ORANGE GROVE AVE SUITE 202
POMONA CA
91767-3031
US

IV. Provider business mailing address

INTERNAL MEDICINE MEDICAL GROUP 840 TOWNE CENTER DRIVE
POMONA CA
91767-5900
US

V. Phone/Fax

Practice location:
  • Phone: 909-623-8796
  • Fax:
Mailing address:
  • Phone: 909-398-1550
  • Fax: 909-398-1573

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 Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ADRIEENE M WALKER
Title or Position: CONTRACTS ADMINISTRATOR
Credential:
Phone: 909-398-1550