Provider Demographics
NPI:1578873444
Name:INLAND EMPIRE SURGICAL GROUP, LLC
Entity Type:Organization
Organization Name:INLAND EMPIRE SURGICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:310-621-0060
Mailing Address - Street 1:8680 MONROE CT
Mailing Address - Street 2:SUITE #100
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4880
Mailing Address - Country:US
Mailing Address - Phone:909-579-3111
Mailing Address - Fax:909-579-3113
Practice Address - Street 1:8680 MONROE CT
Practice Address - Street 2:SUITE #100
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4880
Practice Address - Country:US
Practice Address - Phone:909-579-3111
Practice Address - Fax:909-579-3113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA204E00000X, 207LP2900X, 207RG0100X, 207V00000X, 207X00000X, 207Y00000X, 2082S0099X, 208600000X, 208VP0014X, 213E00000X, 213ER0200X
207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiologyGroup - Multi-Specialty