Provider Demographics
NPI:1053500561
Name:RASOULI MEDICAL GROUP
Entity type:Organization
Organization Name:RASOULI MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GHOLAMREZA
Authorized Official - Middle Name:
Authorized Official - Last Name:RASOULI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-289-4906
Mailing Address - Street 1:700 E REDLANDS BLVD
Mailing Address - Street 2:STE U, # 361
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2101 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4836
Practice Address - Country:US
Practice Address - Phone:909-883-8711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-20
Last Update Date:2007-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85426207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty