Provider Demographics
NPI:1992460794
Name:PROGRESSIVE OB/GYN MEDICAL GROUP INC
Entity type:Organization
Organization Name:PROGRESSIVE OB/GYN MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:H
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-528-3639
Mailing Address - Street 1:PO BOX 10999
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0999
Mailing Address - Country:US
Mailing Address - Phone:909-885-1542
Mailing Address - Fax:
Practice Address - Street 1:1800 WESTERN AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1352
Practice Address - Country:US
Practice Address - Phone:909-885-1542
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-05
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty