Healthcare Provider Details

I. General information

NPI: 1336227362
Provider Name (Legal Business Name): PEDIATRIC MEDICAL GROUP OF RIVERSIDE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6950 BROCKTON AVE
RIVERSIDE CA
92506-3831
US

IV. Provider business mailing address

6950 BROCKTON AVE
RIVERSIDE CA
92506-3831
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-8223
  • Fax: 951-686-9617
Mailing address:
  • Phone: 951-686-8223
  • Fax: 951-686-9617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ROBERTA CLARK
Title or Position: OFFICE MANAGER
Credential:
Phone: 951-686-8223