Provider Demographics
NPI:1194826503
Name:SCOTT C LEDERHAUS MD & LEW B DISNEY MD PRT LEDERHAUS SCOTT C GEN PTR
Entity Type:Organization
Organization Name:SCOTT C LEDERHAUS MD & LEW B DISNEY MD PRT LEDERHAUS SCOTT C GEN PTR
Other - Org Name:INLAND NEUROSURGERY INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-450-0369
Mailing Address - Street 1:255 E BONITA AVE
Mailing Address - Street 2:BUILDING #9
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1923
Mailing Address - Country:US
Mailing Address - Phone:909-450-0369
Mailing Address - Fax:909-450-0366
Practice Address - Street 1:255 E BONITA AVE
Practice Address - Street 2:BUILDING #9
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1923
Practice Address - Country:US
Practice Address - Phone:909-450-0369
Practice Address - Fax:909-450-0366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0099730Medicaid