Basic Information
| Provider Information | |||||||||
| NPI: | 1619943537 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEMET RADIOLOGY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 LAURSEN ST | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925434437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517655417 | ||||||||
| FaxNumber: | 9517655418 | ||||||||
| Practice Location | |||||||||
| Address1: | 1117 E DEVONSHIRE AVE | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925433083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516522811 | ||||||||
| FaxNumber: | 9517654986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | FREDERICK | ||||||||
| AuthorizedOfficialMiddleName: | EUGENE | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR / PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9517655417 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0051940 | 05 | CA | MEDICAID | CH1170 | 01 | CA | RAILROAD MEDICARE | OTHER | GR0051943 | 05 | CA | MEDICAID | GR0051944 | 05 | CA | MEDICAID | CU0238 | 01 | CA | RAILROAD MEDICARE | OTHER | GR0051941 | 05 | CA | MEDICAID | GR0051942 | 05 | CA | MEDICAID |