Basic Information
| Provider Information | |||||||||
| NPI: | 1811968274 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGICAL ASSOCIATES OF SACRAMENTO MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 EXPO PARKWAY | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166468300 | ||||||||
| FaxNumber: | 9169204434 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 BELLA VISTA ROAD | ||||||||
| Address2: | |||||||||
| City: | VACAVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074470400 | ||||||||
| FaxNumber: | 7074470403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 03/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | BRESLAU | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9166468300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085B0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 207U00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | 2085R0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | GR002851A | 05 | CA | MEDICAID |