Basic Information
| Provider Information | |||||||||
| NPI: | 1457476558 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DELTA RADIOLOGY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15498 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958510498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594554000 | ||||||||
| FaxNumber: | 5594554007 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 N CALIFORNIA ST | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952046019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099432000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 12/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | GOLDBERG | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2093344416 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0006153 | 05 | CA | MEDICAID |