Basic Information
| Provider Information | |||||||||
| NPI: | 1891741831 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIANS RADIOLOGY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8400 MIRAMAR RD | ||||||||
| Address2: | 200 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921264387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585641400 | ||||||||
| FaxNumber: | 8585641500 | ||||||||
| Practice Location | |||||||||
| Address1: | 6386 ALVARADO CT | ||||||||
| Address2: | 121 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921204905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192296551 | ||||||||
| FaxNumber: | 6192864524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 11/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | ROBINS | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6192296551 | ||||||||
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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 | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ35437Z | 01 | BLUE SHIELD | OTHER | ZZZ80428Z | 05 | CA | MEDICAID | ZZZ35440Z | 01 | BLUE SHIELD | OTHER | ZZZ80191Z | 05 | CA | MEDICAID |