Basic Information
| Provider Information | |||||||||
| NPI: | 1073000105 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGICA INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 GLASS LN STE C | ||||||||
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| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953569287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Practice Location | |||||||||
| Address1: | 768 MOUNTAIN RANCH RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANDREAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952499707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097542573 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2018 | ||||||||
| LastUpdateDate: | 11/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | ATHWAL | ||||||||
| AuthorizedOfficialFirstName: | PARDEEP | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2097542573 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD, MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A144278 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.