Provider Demographics
NPI:1134118342
Name:MADISON RADIOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MADISON RADIOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF MADISON RADIOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL DOCTOR
Authorized Official - Phone:626-793-8189
Mailing Address - Street 1:223 N 1ST AVE
Mailing Address - Street 2:SUITE #201
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-7089
Mailing Address - Country:US
Mailing Address - Phone:626-793-8189
Mailing Address - Fax:626-795-3975
Practice Address - Street 1:65 N MADISON AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2035
Practice Address - Country:US
Practice Address - Phone:626-793-8189
Practice Address - Fax:626-795-3975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0079230Medicaid
CAZZZ56942ZOtherBLUE SHIELD
CAGR0079230Medicaid