Basic Information
| Provider Information | |||||||||
| NPI: | 1588954929 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MODESTO RADIOLOGY IMAGING, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1524 MCHENRY AVE | ||||||||
| Address2: | # 100 | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095774444 | ||||||||
| FaxNumber: | 2095272069 | ||||||||
| Practice Location | |||||||||
| Address1: | 1524 MCHENRY AVE | ||||||||
| Address2: | # 100 | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095774444 | ||||||||
| FaxNumber: | 2095272069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2011 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | GILBERT | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICER/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 2142368249 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/10/2021 | ||||||||
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.