Organization
LOMA LINDA UNIVERSITY UROLOGY MEDICAL GROUP, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
HERBERT RUCKLE M.D. (GROUP DIRECTOR)
(909) 885-5150
Entity
Organization
Contact information
Practice address
400 N PEPPER AVE, UROLOGY DEPT-6TH FLOOR, COLTON, CA 92324-1801
(909) 885-5150
Mailing address
PO BOX 5157, SAN BERNARDINO, CA 92412-5157
(909) 885-5150
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
GR0056040
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GR0056040
—
CA
01
—
ZZZ33529Z
MEDICARE GROUP NUMBER
—
Enumeration date
10/26/2007
Last updated
10/26/2007
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