Provider Demographics
NPI:1669764205
Name:GAREY ORTHOPEDIC MEDICAL GROUP
Entity type:Organization
Organization Name:GAREY ORTHOPEDIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:LILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-593-7437
Mailing Address - Street 1:255 E BONITA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1923
Mailing Address - Country:US
Mailing Address - Phone:909-593-7437
Mailing Address - Fax:909-593-1958
Practice Address - Street 1:7777 MILLIKEN AVE STE A
Practice Address - Street 2:SUITE 101
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6778
Practice Address - Country:US
Practice Address - Phone:909-987-7696
Practice Address - Fax:909-593-1958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-13
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC28115207X00000X
CAG81163207XS0106X
CAG61462207XS0114X
COA100701207XX0005X
CAA45892207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Single Specialty
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Single Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA33534Medicare UPIN
CAA53645Medicare UPIN
CAE83422Medicare UPIN
CAZZZ23524ZMedicare PIN
CAH00037Medicare UPIN
CAW15819Medicare PIN
4487580001Medicare NSC