Provider Demographics
NPI:1144428350
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:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:KAUFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-570-3108
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:909-570-3108
Mailing Address - Fax:
Practice Address - Street 1:2224 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2638
Practice Address - Country:US
Practice Address - Phone:909-570-3108
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ05740ZOtherMEDICARE PTAN
CAZZZ05740ZMedicare PIN