MEDICARE: PALM IMAGING INSTITUTE, A MEDICAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XS0114X	Adult Reconstructive Orthopaedic Surgery Physician	G55682	CA
2	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	A84930	CA
3	225100000X	Physical Therapist	PT 10673	CA
4	363AS0400X	Surgical Physician Assistant	PA20947	CA
5	2085R0202X	Diagnostic Radiology Physician	28926	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063411460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALM IMAGING INSTITUTE, A MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	399 E 21ST ST
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92404-4815
Country	:	US
Telephone Number	:	909-882-2266
Fax Number	:	909-881-7593

Provider Business Practice Location Address
First Line	:	399 E 21ST ST
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92404-4815
Country	:	US
Telephone Number	:	909-882-2266
Fax Number	:	909-881-7593

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. TANIE DONALDSON
Credential	:	RN
Telephone Number	:	909-882-2266

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	04/23/2018

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