Basic Information
Provider Information | |||||||||
NPI: | 1558342089 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RADIOLOGICAL ASSOCIATES OF SACRAMENTO MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1500 EXPO PKWY | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958154227 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9166468406 | ||||||||
FaxNumber: | 9169204434 | ||||||||
Practice Location | |||||||||
Address1: | 1640 E ROSEVILLE PKWY | ||||||||
Address2: | SUITE 100 | ||||||||
City: | ROSEVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 956613988 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9167842277 | ||||||||
FaxNumber: | 9169321104 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2005 | ||||||||
LastUpdateDate: | 10/28/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRESLAU | ||||||||
AuthorizedOfficialFirstName: | JONATHAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9166468300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085U0001X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X |   | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | GR0092580 | 05 | CA |   | MEDICAID |