Provider Demographics
NPI:1134200983
Name:RENAISSANCE RADIOLOGY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:RENAISSANCE RADIOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MONIKA
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:KIEF-GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-620-8180
Mailing Address - Street 1:8599 HAVEN AVE.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4849
Mailing Address - Country:US
Mailing Address - Phone:909-620-8180
Mailing Address - Fax:909-919-7288
Practice Address - Street 1:8599 HAVEN AVE.
Practice Address - Street 2:SUITE 300
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4849
Practice Address - Country:US
Practice Address - Phone:909-620-8180
Practice Address - Fax:909-919-7288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2085R0202X
2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC08660OtherBUSINESS LICENSE
CAGR0085394Medicaid
CAGR008539CMedicaid
CAGR0085392Medicaid
CAGR008539KMedicaid
CAGR008539FMedicaid
CAGR008539BMedicaid
CAZZZ05740ZMedicare PIN
CAZZZ17311ZMedicare PIN
CAZZZ16508ZMedicare PIN
CAZZZ16499ZMedicare PIN
CAGR008539KMedicaid
CAZZZ18980ZMedicare PIN
CAZZZ16498ZMedicare PIN
CAGR0085392Medicaid
CAZZZ16505ZMedicare PIN
CAZZZ21609ZMedicare PIN
CAZZZ16515ZMedicare PIN
CAZZZ16497ZMedicare PIN
CAC08660OtherBUSINESS LICENSE