Provider Demographics
NPI:1558516179
Name:RIVERSIDE RADIOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:RIVERSIDE RADIOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:MASSEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-781-2270
Mailing Address - Street 1:PO BOX 15648
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95852-0648
Mailing Address - Country:US
Mailing Address - Phone:559-455-4000
Mailing Address - Fax:559-455-4007
Practice Address - Street 1:1770 IOWA AVE
Practice Address - Street 2:280
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2430
Practice Address - Country:US
Practice Address - Phone:951-801-6348
Practice Address - Fax:951-786-0460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABG461AMedicare PIN