Provider Demographics
NPI:1316051261
Name:ORTHOPAEDIC MEDICAL GROUP OF RIVERSIDE, INC.
Entity type:Organization
Organization Name:ORTHOPAEDIC MEDICAL GROUP OF RIVERSIDE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:GUAJARDO
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 1:399 E HIGHLAND AVE
Practice Address - Street 2:SUITE 409
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3808
Practice Address - Country:US
Practice Address - Phone:951-774-4611
Practice Address - Fax:951-276-3597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0393620001Medicare NSC
CAZZZ40607ZMedicare PIN