Provider Demographics
NPI:1528012168
Name:WISHON RADIOLOGICAL MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:WISHON RADIOLOGICAL MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-272-2933
Mailing Address - Street 1:PO BOX 4437
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93744-4437
Mailing Address - Country:US
Mailing Address - Phone:559-485-8330
Mailing Address - Fax:559-485-6994
Practice Address - Street 1:6107 N FRESNO ST
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5207
Practice Address - Country:US
Practice Address - Phone:559-435-4433
Practice Address - Fax:559-485-6994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY34513YMedicare PIN