Basic Information
| Provider Information | |||||||||
| NPI: | 1861473365 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGICAL ASSOCIATES OF SACRAMENTO MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 EXPO PKWY | ||||||||
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| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958154227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166466406 | ||||||||
| FaxNumber: | 9169204434 | ||||||||
| Practice Location | |||||||||
| Address1: | 3581 PALMER DR | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | CAMERON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956828236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306721351 | ||||||||
| FaxNumber: | 5306721385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 10/27/2011 | ||||||||
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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 | 2085R0001X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | GR002851M | 05 | CA | MEDICAID |