Provider Demographics
NPI:1417182510
Name:RADIOLOGY ASSOCIATES OF SAN LUIS OBISPO
Entity Type:Organization
Organization Name:RADIOLOGY ASSOCIATES OF SAN LUIS OBISPO
Other - Org Name:COASTAL DIAGNOSTIC CENTER/ARROYO GRANDE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED SIGNER
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:805-461-7083
Mailing Address - Street 1:PO BOX 8100
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93423-8100
Mailing Address - Country:US
Mailing Address - Phone:805-461-7083
Mailing Address - Fax:805-461-7099
Practice Address - Street 1:921 OAK PARK BLVD
Practice Address - Street 2:SUITE 100B
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3264
Practice Address - Country:US
Practice Address - Phone:805-461-7083
Practice Address - Fax:805-461-7093
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RADIOLOGY ASSOCIATES OF SAN LUIS OBISPO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-19
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW7491Medicare PIN