Provider Demographics
NPI:1558331231
Name:SAN BERNARDINO MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SAN BERNARDINO MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:MALIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-883-8611
Mailing Address - Street 1:1700 NORTH WATERMAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5105
Mailing Address - Country:US
Mailing Address - Phone:909-883-8611
Mailing Address - Fax:909-886-1798
Practice Address - Street 1:1700 NORTH WATERMAN AVENUE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5105
Practice Address - Country:US
Practice Address - Phone:909-883-8611
Practice Address - Fax:909-886-1798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ34371ZMedicare PIN