Provider Demographics
NPI:1700847621
Name:PLACERVILLE RADIOLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PLACERVILLE RADIOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANIETIE
Authorized Official - Middle Name:
Authorized Official - Last Name:OKON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-626-2613
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:681 MAIN ST STE 105
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-0707
Mailing Address - Country:US
Mailing Address - Phone:530-626-1166
Mailing Address - Fax:530-626-3826
Practice Address - Street 1:1100 MARSHALL WAY
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-6533
Practice Address - Country:US
Practice Address - Phone:530-622-1441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-30
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2085B0100X, 2085N0700X, 2085N0904X, 2085R0202X, 2085R0203X, 2085R0204X, 2085R0205X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085R0205XAllopathic & Osteopathic PhysiciansRadiologyRadiological PhysicsGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0053460Medicaid
CAGR0053460Medicaid
CAZZZ79182ZMedicare ID - Type Unspecified