Provider Demographics
NPI:1205905668
Name:INLAND NEPHROLOGY MEDICAL ASSOCIATES INC
Entity type:Organization
Organization Name:INLAND NEPHROLOGY MEDICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BLAKELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-793-7500
Mailing Address - Street 1:251 CAJON ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5260
Mailing Address - Country:US
Mailing Address - Phone:909-793-7500
Mailing Address - Fax:909-792-7890
Practice Address - Street 1:251 CAJON ST
Practice Address - Street 2:SUITE B
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5260
Practice Address - Country:US
Practice Address - Phone:909-793-7500
Practice Address - Fax:909-792-7890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0080390Medicaid
CAZZZ31390ZMedicare PIN