Provider Demographics
NPI:1851404693
Name:NEONATOLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:NEONATOLOGY MEDICAL GROUP INC
Other - Org Name:FONTANA FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:ESCOBAL
Authorized Official - Last Name:MURALIGOPAL
Authorized Official - Suffix:
Authorized Official - Credentials:
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 1:17264 FOOTHILL BLVD
Practice Address - Street 2:STE A B
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-9051
Practice Address - Country:US
Practice Address - Phone:909-428-3900
Practice Address - Fax:909-428-3903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0004461Medicaid