Provider Demographics
NPI:1326461708
Name:REDWOOD RADIOLOGY GROUP INC
Entity Type:Organization
Organization Name:REDWOOD RADIOLOGY GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:E
Authorized Official - Last Name:MODIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-546-4062
Mailing Address - Street 1:PO BOX 5651
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5651
Mailing Address - Country:US
Mailing Address - Phone:714-571-5000
Mailing Address - Fax:714-571-5055
Practice Address - Street 1:121 SOTOYOME ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4823
Practice Address - Country:US
Practice Address - Phone:707-546-4062
Practice Address - Fax:707-525-4095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-21
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ81620YOtherBLUE SHIELD
CAZZZ81615YOtherBLUE SHIELD
CAZZZ81617YOtherBLUE SHIELD
CAZZZ81618YOtherBLUE SHIELD
CAZZZ81619YOtherBLUE SHIELD
CAZZZ81619YOtherBLUE SHIELD