1760856934 NPI number — MODESTO RADIOLOGICAL MEDICAL GROUP, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760856934 NPI number — MODESTO RADIOLOGICAL MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MODESTO RADIOLOGICAL 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:
1760856934
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1524 MCHENRY AVE
Provider Second Line Business Mailing Address:
SUITE 430
Provider Business Mailing Address City Name:
MODESTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95350-4500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-455-4009
Provider Business Mailing Address Fax Number:
916-533-0023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2132 LYSANDER WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95661-3220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-455-4009
Provider Business Practice Location Address Fax Number:
916-533-0023
Provider Enumeration Date:
11/25/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
COO/CFO
Authorized Official Telephone Number:
209-342-5946

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)





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