Provider Demographics
NPI:1821101650
Name:NEONATOLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:NEONATOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VELLORE
Authorized Official - Middle Name:GANESH
Authorized Official - Last Name:MURALIGOPAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-790-5071
Mailing Address - Street 1:PO BOX 8188
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92375-1388
Mailing Address - Country:US
Mailing Address - Phone:909-790-5071
Mailing Address - Fax:909-790-5774
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-6380
Practice Address - Fax:909-580-6361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0004460Medicaid