Provider Demographics
NPI:1831120633
Name:THE RADIATION MEDICAL GROUP INC
Entity Type:Organization
Organization Name:THE RADIATION MEDICAL GROUP INC
Other - Org Name:RADIOSURGERY MEDICAL GROUP INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MYKING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-220-4100
Mailing Address - Street 1:PO BOX 33865
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3865
Mailing Address - Country:US
Mailing Address - Phone:858-888-7700
Mailing Address - Fax:858-888-7721
Practice Address - Street 1:5395 RUFFIN RD
Practice Address - Street 2:STE 103
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1338
Practice Address - Country:US
Practice Address - Phone:858-505-4100
Practice Address - Fax:858-751-0601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7306137Medicaid
CA7306137Medicaid
CA7306137Medicaid