Provider Demographics
NPI:1265982375
Name:SAN BERNARDINO GASTROENTEROLOGY ASSOCIATES INC.
Entity type:Organization
Organization Name:SAN BERNARDINO GASTROENTEROLOGY ASSOCIATES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KUMARARVELU
Authorized Official - Middle Name:
Authorized Official - Last Name:BALASUBRAMANIAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-881-3032
Mailing Address - Street 1:2006 N RIVERSIDE AVE
Mailing Address - Street 2:STE B
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-4696
Mailing Address - Country:US
Mailing Address - Phone:909-881-3032
Mailing Address - Fax:909-881-0668
Practice Address - Street 1:375 TERRACINA BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-3801
Practice Address - Country:US
Practice Address - Phone:909-644-4063
Practice Address - Fax:909-335-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
A447160207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA224209Medicare PIN