Basic Information
| Provider Information | |||||||||
| NPI: | 1477537231 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TUOLUMNE RADIOLOGY GROUP INC | ||||||||
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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: | 1000 GREENLEY RD | ||||||||
| Address2: | |||||||||
| City: | SONORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953705200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 07/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | SCHANER | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2093422300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ75740Z | 01 | CA | BLUE SHEILD | OTHER | GB0009710 | 05 | CA | MEDICAID |