1740232776 NPI number — X-RAY MEDICAL GROUP, INC

Table of content: (NPI 1740232776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740232776 NPI number — X-RAY MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
X-RAY 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:
1740232776
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2527 CRANBERRY HIGHWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAREHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-295-7271
Provider Business Mailing Address Fax Number:
508-273-1241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7777 ALVARADO RD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91941-3616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-460-2770
Provider Business Practice Location Address Fax Number:
619-460-2774
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ELLISON
Authorized Official First Name:
HARRY
Authorized Official Middle Name:
PETER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
619-460-2770

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0013321 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ52314Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ32053Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ32219Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0013320 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ73868Z , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ32220Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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