MEDICARE: ORTHOPAEDIC MEDICAL GROUP OF RIVERSIDE, INC.

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	207X00000X	Orthopaedic Surgery Physician

General Provider Information

NPI Number	:	1144491895
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOPAEDIC MEDICAL GROUP OF RIVERSIDE, INC.

Provider Business Mailing Address
First Line	:	6800 BROCKTON AVE
Second Line	:	2
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3810
Country	:	US
Telephone Number	:	951-774-4611
Fax Number	:	951-276-3597

Provider Business Practice Location Address
First Line	:	6800 BROCKTON AVE
Second Line	:	2
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3810
Country	:	US
Telephone Number	:	951-774-4611
Fax Number	:	951-276-3597

Authorized Official
Title or Position	:	CEO
Name	:	JUAN D GUAJARDO
Credential	:
Telephone Number	:	951-774-4611

Provider Enumeration Date	:	03/20/2008
Last Update Date	:	04/14/2011

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