1720069891 NPI number — NORTHERN CALIFORNIA RADIATION THERAPISTS & ONCOLOGISTS MEDICAL GROUP I

Table of content: (NPI 1720069891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720069891 NPI number — NORTHERN CALIFORNIA RADIATION THERAPISTS & ONCOLOGISTS MEDICAL GROUP I

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN CALIFORNIA RADIATION THERAPISTS & ONCOLOGISTS MEDICAL GROUP I
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:
1720069891
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 GLASS LN STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MODESTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95356-9287
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-342-2300
Provider Business Mailing Address Fax Number:
209-524-4240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2333 BUCHANAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94115-1925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-342-2300
Provider Business Practice Location Address Fax Number:
209-524-4240
Provider Enumeration Date:
11/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
209-342-2300

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  102829 , 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)

  • Identifier: ZZZ27539Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0054561 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ86312Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ75605Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ75605Z , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ86312Z , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ77840Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ77840Z , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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