Provider Demographics
NPI:1306813886
Name:RADIOLOGY ASSOCIATES OF SAN LUIS OBISPO
Entity Type:Organization
Organization Name:RADIOLOGY ASSOCIATES OF SAN LUIS OBISPO
Other - Org Name:FIVE CITIES MEDICAL IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-461-7080
Mailing Address - Street 1:PO BOX 2920
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93423-2920
Mailing Address - Country:US
Mailing Address - Phone:805-461-7080
Mailing Address - Fax:805-464-0243
Practice Address - Street 1:921 OAK PARK BLVD
Practice Address - Street 2:STE 102
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449
Practice Address - Country:US
Practice Address - Phone:805-779-7900
Practice Address - Fax:805-779-7910
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RADIOLOGY ASSOCIATES OF SAN LUIS OBISPO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-03
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0009777Medicaid
W7491Medicare PIN