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NPI Code Detail

MEDICARE: RENAISSANCE RADIOLOGY MEDICAL GROUP, INC.

MEDICARE: RENAISSANCE RADIOLOGY MEDICAL GROUP, 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
12085R0204XVascular & Interventional Radiology PhysicianCA
22085U0001XDiagnostic Ultrasound PhysicianCA
32085R0202XDiagnostic Radiology PhysicianCA

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1CG1263OTHERCARAILROAD MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1952306136
Entity Type Code : Organization
Provider Name (Legal Business Name) : RENAISSANCE RADIOLOGY MEDICAL GROUP, INC.
Provider Business Mailing Address
First Line : 1902 ROYALTY DR
Second Line : STE 220
City : POMONA
State : CA
Zip : 91767-3056
Country : US
Telephone Number : 909-620-8180
Fax Number : 909-469-6741
Provider Business Practice Location Address
First Line : 1805 MEDICAL CENTER DR
Second Line :
City : SAN BERNARDINO
State : CA
Zip : 92411-1217
Country : US
Telephone Number : 909-887-6333
Fax Number :
Authorized Official
Title or Position : PRESIDENT CEO
Name : DR. MONIKA KIEF GARCIA
Credential : M.D.
Telephone Number : 909-620-8180
Provider Enumeration Date : 06/15/2005
Last Update Date : 06/24/2008

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