1992796643 NPI number — MERCED RADIOLOGY MEDICAL GROUP

Table of content: (NPI 1992796643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992796643 NPI number — MERCED RADIOLOGY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCED RADIOLOGY MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992796643
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4301 NORTHSTAR WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MODESTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95356-9262
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-342-2300
Provider Business Mailing Address Fax Number:
209-524-4240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
731 E YOSEMITE AVE
Provider Second Line Business Practice Location Address:
SUITE B-170
Provider Business Practice Location Address City Name:
MERCED
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95340-8039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-342-2300
Provider Business Practice Location Address Fax Number:
209-524-4240
Provider Enumeration Date:
11/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WAGNER
Authorized Official First Name:
MARK
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
209-342-2300

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  8126 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0005283 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0005286 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0005289 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0005282 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0005287 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ25145Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0005280 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0005281 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0005285 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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