Basic Information
| Provider Information | |||||||||
| NPI: | 1902858384 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH COAST RADIOLOGICAL MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5110 E. CLINTON WAY | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937272040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594554065 | ||||||||
| FaxNumber: | 7706669102 | ||||||||
| Practice Location | |||||||||
| Address1: | 24451 HEALTH CENTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | LAGUNA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926533689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494523573 | ||||||||
| FaxNumber: | 9493523573 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 09/16/2022 | ||||||||
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| AuthorizedOfficialLastName: | WASLEY | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | JONATHAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9494523573 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 09/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207U00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | 2085N0700X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 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 | GR0022882 | 05 | CA | MEDICAID | ZZZ73447Z | 05 | CA | MEDICAID | ZZZ74694Z | 05 | CA | MEDICAID | ZZZ14198Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ14199Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ73447Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ14200Z | 01 | CA | BLUE SHIELD | OTHER |