Provider Demographics
NPI:1669492591
Name:EDWARD R SERROS MD INC
Entity Type:Organization
Organization Name:EDWARD R SERROS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-882-0702
Mailing Address - Street 1:7223 CHURCH ST
Mailing Address - Street 2:SUITE A-20
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-5812
Mailing Address - Country:US
Mailing Address - Phone:909-882-0702
Mailing Address - Fax:909-886-6704
Practice Address - Street 1:7223 CHURCH ST
Practice Address - Street 2:SUITE A-20
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-5812
Practice Address - Country:US
Practice Address - Phone:909-882-0702
Practice Address - Fax:909-886-6704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30299207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G302990Medicaid
CAZZZ12185ZMedicare ID - Type Unspecified
CA00G302990Medicaid