Basic Information
| Provider Information | |||||||||
| NPI: | 1861451858 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FULLERTON RADIOLOGY MEDICAL GROUP, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3350 E BIRCH ST | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | BREA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928216264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149920850 | ||||||||
| FaxNumber: | 7145268271 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 N ROSE DR | ||||||||
| Address2: | |||||||||
| City: | PLACENTIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928703802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149932000 | ||||||||
| FaxNumber: | 7145244216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2006 | ||||||||
| LastUpdateDate: | 08/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHAN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7145262241 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | 08/26/2021 | ||||||||
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 | GR0006737 | 05 | CA | MEDICAID | ZZZ74739Z | 01 | CA | BLUE SHIELD OF CALIF | OTHER | ZZZ74739Z | 05 | CA | MEDICAID | ZZZ75588Z | 01 | CA | BLUE SHIELD OF CALIF | OTHER | ZZZ642972 | 01 | CA | BLUE SHIELD OF CALIF | OTHER | GR0006738 | 05 | CA | MEDICAID | GR0006731 | 05 | CA | MEDICAID | GR0006736 | 05 | CA | MEDICAID |