Provider Demographics
NPI:1447263066
Name:INLAND HEART DOCTORS MEDICAL GROUP
Entity type:Organization
Organization Name:INLAND HEART DOCTORS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSCOSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-734-4880
Mailing Address - Street 1:2250 S MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-5302
Mailing Address - Country:US
Mailing Address - Phone:951-734-4880
Mailing Address - Fax:951-734-7963
Practice Address - Street 1:2250 S MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-5302
Practice Address - Country:US
Practice Address - Phone:951-734-4880
Practice Address - Fax:951-734-7963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0084190Medicaid
CAZZZ15455ZMedicare PIN