Provider Demographics
NPI: | 1508847096 |
---|---|
Name: | RADIOLOGICAL ASSOCIATES OF SACRAMENTO MEDICAL GROUP |
Entity Type: | Organization |
Organization Name: | RADIOLOGICAL ASSOCIATES OF SACRAMENTO MEDICAL GROUP |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | JONATHAN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BRESLAU |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 916-646-8300 |
Mailing Address - Street 1: | 1500 EXPO PKWY |
Mailing Address - Street 2: | |
Mailing Address - City: | SACRAMENTO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 95815-4227 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 916-646-8406 |
Mailing Address - Fax: | 916-920-4434 |
Practice Address - Street 1: | 3123 PROFESSIONAL DR |
Practice Address - Street 2: | STE 100 |
Practice Address - City: | AUBURN |
Practice Address - State: | CA |
Practice Address - Zip Code: | 95603-2462 |
Practice Address - Country: | US |
Practice Address - Phone: | 530-888-8878 |
Practice Address - Fax: | 530-888-7635 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2005-11-10 |
Last Update Date: | 2011-10-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
207U00000X, 207UN0901X, 207UN0902X, 207UN0903X, 2085N0700X, 2085N0904X, 2085R0203X, 2085R0204X, 2085R0205X | ||
CA | 2085B0100X, 2085R0202X, 2085U0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 2085N0700X | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | Group - Multi-Specialty |
No | 207U00000X | Allopathic & Osteopathic Physicians | Nuclear Medicine | Group - Multi-Specialty | |
No | 207UN0901X | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | Group - Multi-Specialty |
No | 207UN0902X | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy | Group - Multi-Specialty |
No | 207UN0903X | Allopathic & Osteopathic Physicians | Nuclear Medicine | In Vivo & In Vitro Nuclear Medicine | Group - Multi-Specialty |
No | 2085B0100X | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | Group - Multi-Specialty |
No | 2085N0904X | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | Group - Multi-Specialty |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 2085R0203X | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | Group - Multi-Specialty |
No | 2085R0204X | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | Group - Multi-Specialty |
No | 2085R0205X | Allopathic & Osteopathic Physicians | Radiology | Radiological Physics | Group - Multi-Specialty |
No | 2085U0001X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | GR002851R | Medicaid | |
CA | ZZZ10844Z | Medicare PIN |