1710158498 NPI number — ON-LINE RADIOLOGY MEDICAL GROUP INC

Table of content: (NPI 1710158498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710158498 NPI number — ON-LINE RADIOLOGY MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ON-LINE RADIOLOGY MEDICAL GROUP INC
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:
1710158498
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5594
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAROL STREAM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60197-5594
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-509-8452
Provider Business Mailing Address Fax Number:
508-273-1241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1770 IOWA AVE
Provider Second Line Business Practice Location Address:
SUITE 280
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92507-2430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-848-5876
Provider Business Practice Location Address Fax Number:
855-226-5960
Provider Enumeration Date:
03/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SALEN
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
951-786-0801

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0200X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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