Basic Information
| Provider Information | |||||||||
| NPI: | 1932516754 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED IMAGING OF TRACY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 398076 | ||||||||
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| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941398076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098332393 | ||||||||
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| Practice Location | |||||||||
| Address1: | 520 WEST I STREET | ||||||||
| Address2: | |||||||||
| City: | LOS BANOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953365964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098332393 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2014 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | PORZIO | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MD/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2098332393 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.