Provider Demographics
NPI:1902848740
Name:RADIATION MEDICAL GROUP
Entity Type:Organization
Organization Name:RADIATION MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/CFO
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 1:4025 CAMINO DEL RIO S
Mailing Address - Street 2:STE 101
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4107
Mailing Address - Country:US
Mailing Address - Phone:619-220-4100
Mailing Address - Fax:
Practice Address - Street 1:5395 RUFFIN RD
Practice Address - Street 2:STE 103B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1338
Practice Address - Country:US
Practice Address - Phone:619-505-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13257Medicare ID - Type Unspecified