Provider Demographics
NPI:1326086703
Name:TUSTIN TELERADIOLOGY MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:TUSTIN TELERADIOLOGY MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:ATLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-665-6900
Mailing Address - Street 1:13422 NEWPORT AVE
Mailing Address - Street 2:SUITE I
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3746
Mailing Address - Country:US
Mailing Address - Phone:714-665-6900
Mailing Address - Fax:714-665-6904
Practice Address - Street 1:13422 NEWPORT AVE
Practice Address - Street 2:SUITE I
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3746
Practice Address - Country:US
Practice Address - Phone:714-665-6900
Practice Address - Fax:714-665-6904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2019-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG745352471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G745350Medicaid
NV002082232Medicaid
CAZZZ57939ZOtherBLUE SHIELD GROUP NUMBER
CA00G745350Medicaid