Basic Information
| Provider Information | |||||||||
| NPI: | 1992796643 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCED RADIOLOGY MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 NORTHSTAR WAY | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953569262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Practice Location | |||||||||
| Address1: | 731 E YOSEMITE AVE | ||||||||
| Address2: | SUITE B-170 | ||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953408039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 10/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2093422300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 8126 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0005283 | 05 | CA | MEDICAID | GR0005286 | 05 | CA | MEDICAID | GR0005289 | 05 | CA | MEDICAID | GR0005282 | 05 | CA | MEDICAID | GR0005287 | 05 | CA | MEDICAID | ZZZ25145Z | 01 | CA | BLUE SHIELD | OTHER | GR0005280 | 05 | CA | MEDICAID | GR0005281 | 05 | CA | MEDICAID | GR0005285 | 05 | CA | MEDICAID |