Basic Information
| Provider Information | |||||||||
| NPI: | 1548297088 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN DIEGO DIAGNOSTIC RADIOLOGY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23540 | ||||||||
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| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921933540 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 765 MEDICAL CENTER CT | ||||||||
| Address2: | SAN DIEGO IMAGING - CHULA VISTA | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919116600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193976577 | ||||||||
| FaxNumber: | 6193975182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 03/22/2017 | ||||||||
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| AuthorizedOfficialLastName: | PADELFORD | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8585650950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085B0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085N0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | GR0083811 | 05 | CA | MEDICAID |