Provider Demographics
NPI:1992723555
Name:RENAISSANCE RADIOLOGY MEDICAL GROUP INC
Entity type:Organization
Organization Name:RENAISSANCE RADIOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIEF GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-620-8180
Mailing Address - Street 1:1902 ROYALTY DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3030
Mailing Address - Country:US
Mailing Address - Phone:909-620-8180
Mailing Address - Fax:909-469-6741
Practice Address - Street 1:12276 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5838
Practice Address - Country:US
Practice Address - Phone:909-620-8180
Practice Address - Fax:909-469-6741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2085R0202X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0085391Medicaid
CAGR0085391Medicaid