Provider Demographics
NPI:1508864000
Name:RADIATION MEDICAL GROUP INC
Entity Type:Organization
Organization Name:RADIATION MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:MYKING
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:619-220-4100
Mailing Address - Street 1:PO BOX 33865
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3865
Mailing Address - Country:US
Mailing Address - Phone:619-220-4100
Mailing Address - Fax:619-270-3423
Practice Address - Street 1:6699 ALVARADO RD
Practice Address - Street 2:STE 2109
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5238
Practice Address - Country:US
Practice Address - Phone:619-229-3838
Practice Address - Fax:619-229-3849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0062072Medicaid
CAGR0062072Medicaid
CAW13257Medicare PIN
CAW13257EMedicare ID - Type Unspecified