Provider Demographics
NPI:1316140619
Name:INTERNAL MEDICINE MEDICAL GROUP
Entity type:Organization
Organization Name:INTERNAL MEDICINE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-398-1550
Mailing Address - Street 1:840 TOWNE CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3031
Mailing Address - Country:US
Mailing Address - Phone:909-398-1550
Mailing Address - Fax:909-398-1573
Practice Address - Street 1:1866 N ORANGE GROVE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3031
Practice Address - Country:US
Practice Address - Phone:909-865-0676
Practice Address - Fax:909-865-8483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0011290Medicaid
CAG42790AMedicare PIN
CAGR0011290Medicaid