Provider Demographics
NPI:1386724433
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 ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ADRIEENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-398-1550
Mailing Address - Street 1:INTERNAL MEDICINE MEDICAL GROUP
Mailing Address - Street 2:840 TOWNE CENTER DRIVE
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
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 202
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3031
Practice Address - Country:US
Practice Address - Phone:909-623-8796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0011290Medicaid
CAW1165Medicare PIN
CAGR0011290Medicaid