Provider Demographics
NPI:1659496750
Name:DELTA RADIOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:DELTA RADIOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-334-4416
Mailing Address - Street 1:PO BOX 15498
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95851-0498
Mailing Address - Country:US
Mailing Address - Phone:559-455-4000
Mailing Address - Fax:559-455-4007
Practice Address - Street 1:1617 N CALIFORNIA ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6117
Practice Address - Country:US
Practice Address - Phone:209-948-6063
Practice Address - Fax:209-948-2661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0006151Medicaid
CAGR0006151Medicaid
CAZZZ19725ZMedicare PIN