Basic Information
| Provider Information | |||||||||
| NPI: | 1437168861 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH BAY RADIOLOGY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3222 | ||||||||
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| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945580293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072617823 | ||||||||
| FaxNumber: | 7072563508 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 JANES RD | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955214742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078254972 | ||||||||
| FaxNumber: | 7078254919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 09/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | ROOT | ||||||||
| AuthorizedOfficialFirstName: | WESLEY | ||||||||
| AuthorizedOfficialMiddleName: | EATON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7072617880 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A23851 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00A238510 | 05 | CA | MEDICAID |