Provider Demographics
NPI:1225012644
Name:RENAISSANCE RADIOLOGY MED GRP INC
Entity Type:Organization
Organization Name:RENAISSANCE RADIOLOGY MED GRP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:MONIKA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KIEF GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-620-8180
Mailing Address - Street 1:1902 ROYALTY DRIVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767
Mailing Address - Country:US
Mailing Address - Phone:909-620-8180
Mailing Address - Fax:909-469-6741
Practice Address - Street 1:2101 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4836
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:2005-11-30
Last Update Date:2008-06-24
Deactivation Date:2007-08-28
Deactivation Code:
Reactivation Date:2007-10-11
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
CAGR008539FMedicaid
CACG1263OtherRAILROAD MEDICARE
CAGR008539FMedicaid