Provider Demographics
NPI:1306854294
Name:RADIOLOGY MEDICAL GROUP OF SANTA CRUZ COUNTY INC
Entity Type:Organization
Organization Name:RADIOLOGY MEDICAL GROUP OF SANTA CRUZ COUNTY INC
Other - Org Name:SOUTH COUNTY IMAGING
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:AVERILL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:831-476-1542
Mailing Address - Street 1:1661 SOQUEL DRIVE
Mailing Address - Street 2:BUILDING G
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1709
Mailing Address - Country:US
Mailing Address - Phone:831-476-1542
Mailing Address - Fax:831-464-8977
Practice Address - Street 1:108 B GREEN VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019-3110
Practice Address - Country:US
Practice Address - Phone:831-724-2236
Practice Address - Fax:831-724-8440
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RADIOLOGY MEDICAL GROUP OF SANTA CRUZ COUNTY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-04
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ73808ZOtherBLUE SHIELD
CAZZZ73806ZMedicaid
ZZZ73806ZMedicare PIN
CN8304Medicare PIN