Healthcare Provider Details

I. General information

NPI: 1992460794
Provider Name (Legal Business Name): PROGRESSIVE OB/GYN MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2021
Last Update Date: 11/06/2021
Certification Date: 11/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 WESTERN AVE STE 101
SAN BERNARDINO CA
92411-1352
US

IV. Provider business mailing address

PO BOX 10999
SAN BERNARDINO CA
92423-0999
US

V. Phone/Fax

Practice location:
  • Phone: 909-885-1542
  • Fax:
Mailing address:
  • Phone: 909-885-1542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GEORGE H SMALL
Title or Position: OWNER
Credential: MD
Phone: 909-528-3639