Provider Demographics
NPI:1316997596
Name:LOMA LINDA UNIVERSITY CARDIOLOGY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:LOMA LINDA UNIVERSITY CARDIOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:JUTZY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-558-4200
Mailing Address - Street 1:PO BOX 10427
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0427
Mailing Address - Country:US
Mailing Address - Phone:909-558-8591
Mailing Address - Fax:909-558-0118
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-4200
Practice Address - Fax:909-558-7975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0042260Medicaid
CAW15996Medicare PIN
CAGR0042260Medicaid