Basic Information
| Provider Information | |||||||||
| NPI: | 1629033030 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FUSION DIAGNOSTIC GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94592 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981246892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003629772 | ||||||||
| FaxNumber: | 2062723599 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 CALIFORNIA STREET | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159217226 | ||||||||
| FaxNumber: | 4159217225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 10/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | DIMARTINO | ||||||||
| AuthorizedOfficialFirstName: | NICK | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP CFO OF MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2062723580 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | IDTF00290 | 05 | CA | MEDICAID | 470001751 | 01 | RAILROAD MEDICARE | OTHER |