Provider Demographics
NPI:1083705081
Name:RENOLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:RENOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-956-2111
Mailing Address - Street 1:1510 S CENTRAL AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2500
Mailing Address - Country:US
Mailing Address - Phone:818-956-2111
Mailing Address - Fax:818-956-2122
Practice Address - Street 1:1510 S CENTRAL AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2500
Practice Address - Country:US
Practice Address - Phone:818-956-2111
Practice Address - Fax:818-956-2122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24092207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A240920Medicaid
CA00A240920Medicaid
CAW4900Medicare PIN