Basic Information
| Provider Information | |||||||||
| NPI: | 1740232776 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | X-RAY MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2527 CRANBERRY HIGHWAY | ||||||||
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| City: | WAREHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5082957271 | ||||||||
| FaxNumber: | 5082731241 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 ALVARADO RD | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919413616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194602770 | ||||||||
| FaxNumber: | 6194602774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | ELLISON | ||||||||
| AuthorizedOfficialFirstName: | HARRY | ||||||||
| AuthorizedOfficialMiddleName: | PETER | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6194602770 | ||||||||
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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 | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0013321 | 05 | CA | MEDICAID | ZZZ52314Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ32053Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ32219Z | 01 | CA | BLUE SHIELD | OTHER | GR0013320 | 05 | CA | MEDICAID | ZZZ73868Z | 05 | CA | MEDICAID | ZZZ32220Z | 01 | CA | BLUE SHIELD | OTHER |