Provider Demographics
NPI:1346271533
Name:INLAND CARDIOTHORACIC SURGICAL ASSOCIATES MEDICAL GROUP
Entity Type:Organization
Organization Name:INLAND CARDIOTHORACIC SURGICAL ASSOCIATES MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:L
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:CMA
Authorized Official - Phone:909-881-1614
Mailing Address - Street 1:401 E HIGHLAND AVE
Mailing Address - Street 2:SUITE 251
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3803
Mailing Address - Country:US
Mailing Address - Phone:909-881-1614
Mailing Address - Fax:909-881-2711
Practice Address - Street 1:16051 KASOTA RD
Practice Address - Street 2:SUITE 900
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2215
Practice Address - Country:US
Practice Address - Phone:760-946-8181
Practice Address - Fax:760-946-8184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0049932Medicaid
CAZZZ15480ZMedicare ID - Type Unspecified