Basic Information
| Provider Information | |||||||||
| NPI: | 1275523151 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED IMAGING OF TRACY LLC | ||||||||
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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: | 1530 BESSIE AVE | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | TRACY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953763080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RONDOWANSKI | ||||||||
| AuthorizedOfficialFirstName: | TERRI | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2093422300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 69105 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ07670Z | 01 | CA | BLUE SHIELD | OTHER |