Provider Demographics
NPI:1679574594
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:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KERKAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-781-2270
Mailing Address - Street 1:PO BOX 52499
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92517-3499
Mailing Address - Country:US
Mailing Address - Phone:951-781-2270
Mailing Address - Fax:951-787-6628
Practice Address - Street 1:12276 HESPERIA RD
Practice Address - Street 2:STE 6
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5838
Practice Address - Country:US
Practice Address - Phone:760-843-0995
Practice Address - Fax:760-843-0975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2022-07-21
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
CAZZZ751532Medicaid
CACG9918OtherNONE
CACG9918OtherNONE