Basic Information
| Provider Information | |||||||||
| NPI: | 1457653206 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE RADIOLOGY MEDICAL GROUP, INC. | ||||||||
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| Address1: | 1660 CHICAGO AVE | ||||||||
| Address2: | SUITE M-17 | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925072068 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3651 LAKETREE DR | ||||||||
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| City: | FALLBROOK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920289404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594554000 | ||||||||
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| ProviderEnumerationDate: | 11/30/2010 | ||||||||
| LastUpdateDate: | 11/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | MASSEE | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9517812273 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 |
No ID Information.