1790189389 NPI number — ON-LINE RADIOLOGY 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 1790189389 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:
1790189389
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:
1770 IOWA AVE
Provider Second Line Business Mailing Address:
280
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92507-2430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-786-0801
Provider Business Mailing Address Fax Number:
877-892-0278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28062 BAXTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MURRIETA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92563-1401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-455-4068
Provider Business Practice Location Address Fax Number:
770-666-9103
Provider Enumeration Date:
10/10/2014

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , 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)





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