Basic Information
| Provider Information | |||||||||
| NPI: | 1184606162 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARIN RADIATION ONCOLOGY MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 NORTHSTAR WAY | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953569262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 S ELISEO DR | ||||||||
| Address2: | 100 | ||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949042011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 12/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | TORIGOE | ||||||||
| AuthorizedOfficialFirstName: | ERNEST | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR MEDICAL | ||||||||
| AuthorizedOfficialTelephone: | 2093422300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | GR0046360 | 05 | CA | MEDICAID | ZZZ25782Z | 01 | CA | BLUE SHIELD | OTHER |