Provider Demographics
NPI:1083724850
Name:INLAND PHYSICIANS SERVICE INC
Entity Type:Organization
Organization Name:INLAND PHYSICIANS SERVICE INC
Other - Org Name:INLAND REGION MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PHYSICAN PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WOODBURY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-483-0505
Mailing Address - Street 1:9089 BASELINE ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:909-483-0505
Mailing Address - Fax:909-483-0508
Practice Address - Street 1:9089 BASELINE ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-483-0505
Practice Address - Fax:909-483-0508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0061231Medicaid
CADA1449OtherMEDICARE RAILROAD
CAZZZ25561ZMedicare ID - Type Unspecified
W16209Medicare ID - Type UnspecifiedSOUTH