Basic Information
| Provider Information | |||||||||
| NPI: | 1942226329 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRASS VALLEY RADIOLOGY MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 496084 | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960496084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302410473 | ||||||||
| FaxNumber: | 5302415377 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 GLASSON WAY | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959455723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302746107 | ||||||||
| FaxNumber: | 5302746059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 08/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | ENGEL | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5302746107 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.