Provider Demographics
NPI:1831129543
Name:THERAPEUTIC RADIOLOGY MEDICAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:THERAPEUTIC RADIOLOGY MEDICAL ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MANOUCH
Authorized Official - Middle Name:
Authorized Official - Last Name:AZAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-572-7237
Mailing Address - Street 1:1700 COFFEE RD
Mailing Address - Street 2:DEPARTMENT OF RADIATION ONCOLOGY
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2803
Mailing Address - Country:US
Mailing Address - Phone:209-572-7237
Mailing Address - Fax:209-526-5280
Practice Address - Street 1:1700 COFFEE RD
Practice Address - Street 2:DEPARTMENT OF RADIATION ONCOLOGY
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2803
Practice Address - Country:US
Practice Address - Phone:209-572-7237
Practice Address - Fax:209-526-5280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0078260Medicaid
CAGR0078260Medicaid