Provider Demographics
NPI:1578516829
Name:RADIOLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:RADIOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:BUCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-291-4474
Mailing Address - Street 1:PO BOX 5667
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5667
Mailing Address - Country:US
Mailing Address - Phone:714-571-5000
Mailing Address - Fax:714-571-5055
Practice Address - Street 1:4077 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2105
Practice Address - Country:US
Practice Address - Phone:619-294-8111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0078613Medicaid
CAGR0078614Medicaid
CAGR0078617Medicaid
ZZZ02300ZOtherBLUE SHIELD
CAGR0078612Medicaid
ZZZ06212ZOtherBLUE SHIELD
ZZZ64124ZOtherBLUE SHIELD
ZZZ54147ZOtherBLUE SHIELD
ZZZ07025ZOtherBLUE SHIELD
ZZZ08896ZOtherBLUE SHIELD
ZZZ08896ZOtherBLUE SHIELD
CAGR0078613Medicaid
ZZZ07025ZOtherBLUE SHIELD
CAHW14057Medicare PIN
CACD4811Medicare PIN
CAGR0078612Medicaid
CAGR0078614Medicaid
CAW14057AMedicare PIN