Provider Demographics
NPI:1740232776
Name:X-RAY MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:X-RAY MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-460-2770
Mailing Address - Street 1:2527 CRANBERRY HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02571
Mailing Address - Country:US
Mailing Address - Phone:508-295-7271
Mailing Address - Fax:508-273-1241
Practice Address - Street 1:7777 ALVARADO RD
Practice Address - Street 2:SUITE 108
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-3616
Practice Address - Country:US
Practice Address - Phone:619-460-2770
Practice Address - Fax:619-460-2774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0013321Medicaid
CAZZZ52314ZOtherBLUE SHIELD
CAZZZ32053ZOtherBLUE SHIELD
CAZZZ32219ZOtherBLUE SHIELD
CAGR0013320Medicaid
CAZZZ73868ZMedicaid
CAZZZ32220ZOtherBLUE SHIELD
CAHW189Medicare PIN
CAGR0013321Medicaid
CAHW189EMedicare PIN