Basic Information
| Provider Information | |||||||||
| NPI: | 1720256605 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROGRESSIVE RADIOLOGY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 MARINA VILLAGE PKWY | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | ALAMEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945011087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108659670 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1860 EL CAMINO REAL | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BURLINGAME | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940103127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108659670 | ||||||||
| FaxNumber: | 5108659680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2008 | ||||||||
| LastUpdateDate: | 02/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | MOELLEKEN | ||||||||
| AuthorizedOfficialFirstName: | SONJA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4153214682 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROGRESSIVE RADIOLOGY SERVICES | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.