Provider Demographics
NPI:1790850238
Name:RELIANT RADIOLOGY MEDICAL GROUP A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:RELIANT RADIOLOGY MEDICAL GROUP A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:BENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-488-2909
Mailing Address - Street 1:PO BOX 7659
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93290-7659
Mailing Address - Country:US
Mailing Address - Phone:559-627-6363
Mailing Address - Fax:559-627-6367
Practice Address - Street 1:816 W ACEQUIA AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-6126
Practice Address - Country:US
Practice Address - Phone:559-627-6363
Practice Address - Fax:559-627-3627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG391722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0090100Medicaid
CAGR0090100Medicaid
HW15274Medicare PIN