Basic Information
| Provider Information | |||||||||
| NPI: | 1528012168 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WISHON RADIOLOGICAL MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4437 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937444437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594858330 | ||||||||
| FaxNumber: | 5594856994 | ||||||||
| Practice Location | |||||||||
| Address1: | 6107 N FRESNO ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937105207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594354433 | ||||||||
| FaxNumber: | 5594856994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 06/21/2010 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | CHARLES | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 5592722933 | ||||||||
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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 | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.