Provider Demographics
NPI:1639126725
Name:EL CAMINO RADIOLOGISTS MEDICAL GROUP
Entity Type:Organization
Organization Name:EL CAMINO RADIOLOGISTS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VOLNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDALSEM
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:650-940-7044
Mailing Address - Street 1:PO BOX 6102
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-6102
Mailing Address - Country:US
Mailing Address - Phone:415-884-3404
Mailing Address - Fax:415-883-1836
Practice Address - Street 1:2500 GRANT RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4302
Practice Address - Country:US
Practice Address - Phone:650-940-7044
Practice Address - Fax:650-940-7134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CI9619OtherRAILROAD MEDICARE PIN
CAGR0010800Medicaid
CAGR0010800Medicaid