MEDICARE: PEDIATRIC 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	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1336227362
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC MEDICAL GROUP OF RIVERSIDE INC.

Provider Business Mailing Address
First Line	:	6950 BROCKTON AVE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3831
Country	:	US
Telephone Number	:	951-686-8223
Fax Number	:	951-686-9617

Provider Business Practice Location Address
First Line	:	6950 BROCKTON AVE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3831
Country	:	US
Telephone Number	:	951-686-8223
Fax Number	:	951-686-9617

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. ROBERTA CLARK
Credential	:
Telephone Number	:	951-686-8223

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	08/22/2020

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