Provider Demographics
NPI:1215965645
Name:ORTHOPAEDIC MEDICAL GROUP OF RIVERSIDE, INC.
Entity type:Organization
Organization Name:ORTHOPAEDIC MEDICAL GROUP OF RIVERSIDE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADM. ASSIST.
Authorized Official - Prefix:MRS
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-774-4611
Mailing Address - Street 1:6850 BROCKTON AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3808
Mailing Address - Country:US
Mailing Address - Phone:951-774-4611
Mailing Address - Fax:951-276-3597
Practice Address - Street 1:6485 DAY ST
Practice Address - Street 2:SUITE 303
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0929
Practice Address - Country:US
Practice Address - Phone:951-635-0170
Practice Address - Fax:951-697-8961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0393620001Medicare NSC
CAZZZ40607ZMedicare PIN