1346646353 NPI number — ONLINE RADIOLOGY MEDICAL GROUP, INC.

Table of content: MR. GARY C. GOLDMAN LMT (NPI 1326164104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346646353 NPI number — ONLINE RADIOLOGY MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ONLINE 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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1346646353
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 REMITTANCE DR
Provider Second Line Business Mailing Address:
DEPT. 6620
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60675-6620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-412-2639
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
135 S HASKELL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-5547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-960-0562
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/18/2014

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  A76226 , 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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