Healthcare Provider Details

I. General information

NPI: 1548254980
Provider Name (Legal Business Name): INLAND HOSPITALISTS MED GP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 04/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11705 SLATE AVE
RIVERSIDE CA
92505-5196
US

IV. Provider business mailing address

PO BOX 80590
SAN MARINO CA
91118-8590
US

V. Phone/Fax

Practice location:
  • Phone: 951-351-7726
  • Fax:
Mailing address:
  • Phone: 714-692-5180
  • Fax: 714-692-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: EDGAR ARDILA
Title or Position: OWNER
Credential: MD
Phone: 714-692-5180