Provider Demographics
NPI:1861451858
Name:FULLERTON RADIOLOGY MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:FULLERTON RADIOLOGY MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:714-526-2241
Mailing Address - Street 1:3350 E BIRCH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-6264
Mailing Address - Country:US
Mailing Address - Phone:714-992-0850
Mailing Address - Fax:714-526-8271
Practice Address - Street 1:1301 N ROSE DR
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-3802
Practice Address - Country:US
Practice Address - Phone:714-993-2000
Practice Address - Fax:714-524-4216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-20
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0006737Medicaid
CAZZZ74739ZOtherBLUE SHIELD OF CALIF
CAZZZ74739ZMedicaid
CAZZZ75588ZOtherBLUE SHIELD OF CALIF
CAZZZ642972OtherBLUE SHIELD OF CALIF
CAGR0006738Medicaid
CAGR0006731Medicaid
CAGR0006736Medicaid
CAHW531Medicare PIN
CAGR0006731Medicaid
CAZZZ74739ZOtherBLUE SHIELD OF CALIF
CAZZZ74739ZMedicaid
CAHW531AMedicare PIN
CAHW531GMedicare PIN