Provider Demographics
NPI:1568668739
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:
Authorized Official - Last Name:KAUFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-620-8180
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:909-620-8180
Mailing Address - Fax:
Practice Address - Street 1:5470 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-3517
Practice Address - Country:US
Practice Address - Phone:909-620-8180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR008539EMedicaid
CAZZZ16515ZMedicare PIN