Provider Demographics
NPI:1134670656
Name:MODESTO RADIOLOGICAL MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:MODESTO RADIOLOGICAL MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-342-5946
Mailing Address - Street 1:PO BOX 7326
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94120-7326
Mailing Address - Country:US
Mailing Address - Phone:559-455-4009
Mailing Address - Fax:916-533-0313
Practice Address - Street 1:8673 JULIE LYNNE CIR
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95304-9207
Practice Address - Country:US
Practice Address - Phone:209-342-5946
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty