Basic Information
| Provider Information | |||||||||
| NPI: | 1073969838 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MODESTO RADIOLOGICAL MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1524 MCHENRY AVE | ||||||||
| Address2: | STE 430 | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594554009 | ||||||||
| FaxNumber: | 9165330313 | ||||||||
| Practice Location | |||||||||
| Address1: | 148 BEACHVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950603008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594554009 | ||||||||
| FaxNumber: | 9165330313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2016 | ||||||||
| LastUpdateDate: | 05/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 2093425946 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.