Basic Information
| Provider Information | |||||||||
| NPI: | 1386811230 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SACRAMENTO RADIOLOGY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 276010 | ||||||||
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| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958276010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163634040 | ||||||||
| FaxNumber: | 9163636715 | ||||||||
| Practice Location | |||||||||
| Address1: | 2110 PROFESSIONAL DR | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956613752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167870404 | ||||||||
| FaxNumber: | 9167870434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2008 | ||||||||
| LastUpdateDate: | 05/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | OWYANG | ||||||||
| AuthorizedOfficialFirstName: | SIGRID | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9163634040 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR001137J | 01 | CA | MEDI-CAL | OTHER | ZZZ17569Z | 01 | BLUE SHIELD | OTHER |