Basic Information
| Provider Information | |||||||||
| NPI: | 1720069891 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN CALIFORNIA RADIATION THERAPISTS & ONCOLOGISTS MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 NORTHSTAR WAY | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953569262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Practice Location | |||||||||
| Address1: | 2333 BUCHANAN ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941151925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 12/06/2007 | ||||||||
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| AuthorizedOfficialLastName: | GLAUBIGER | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | LEO | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2093422300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 102829 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ27539Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ75605Z | 01 | CA | BLUE SHIELD | OTHER | GR0054561 | 05 | CA | MEDICAID | ZZZ75605Z | 05 | CA | MEDICAID | ZZZ86312Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ86312Z | 05 | CA | MEDICAID | ZZZ77840Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ77840Z | 05 | CA | MEDICAID |