Healthcare Provider Details

I. General information

NPI: 1861956971
Provider Name (Legal Business Name): NEW AGE GASTROENTEROLOGY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 E REDLANDS BLVD STE K
SAN BERNARDINO CA
92408-3760
US

IV. Provider business mailing address

PO BOX 8126
REDLANDS CA
92375-1326
US

V. Phone/Fax

Practice location:
  • Phone: 909-654-2199
  • Fax: 909-798-8765
Mailing address:
  • Phone: 909-654-2199
  • Fax: 909-798-8765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: KEISHA L BALDEOSINGH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 909-654-2199