Basic Information
| Provider Information | |||||||||
| NPI: | 1255819892 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JUDE RADIOLOGY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26570 | ||||||||
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| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937296570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149923978 | ||||||||
| FaxNumber: | 7144465908 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 E VALENCIA MESA DR | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928353809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149923000 | ||||||||
| FaxNumber: | 9165330313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2018 | ||||||||
| LastUpdateDate: | 02/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5594554109 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.