Provider Demographics
NPI:1710158498
Name:ON-LINE RADIOLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:ON-LINE RADIOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SALEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-786-0801
Mailing Address - Street 1:PO BOX 5594
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60197-5594
Mailing Address - Country:US
Mailing Address - Phone:866-509-8452
Mailing Address - Fax:508-273-1241
Practice Address - Street 1:1770 IOWA AVE
Practice Address - Street 2:SUITE 280
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2430
Practice Address - Country:US
Practice Address - Phone:800-848-5876
Practice Address - Fax:855-226-5960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2085R0202X
CA261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACQ290BMedicare UPIN
NMNMAAA0823Medicare UPIN
MOMA4554Medicare UPIN
CACQ290AMedicare PIN
OHH033390Medicare UPIN
ILIL5522Medicare UPIN