Provider Demographics
NPI:1952351074
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:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:FIDES
Authorized Official - Middle Name:P
Authorized Official - Last Name:ESCOBAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-428-3900
Mailing Address - Street 1:17264 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-9050
Mailing Address - Country:US
Mailing Address - Phone:909-428-3900
Mailing Address - Fax:909-428-3903
Practice Address - Street 1:17264 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-9050
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:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78188173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A296540OtherMEDI-CAL