Provider Demographics
NPI:1902858384
Name:SOUTH COAST RADIOLOGICAL MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SOUTH COAST RADIOLOGICAL MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JONATHAN
Authorized Official - Last Name:WASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-452-3573
Mailing Address - Street 1:5110 E. CLINTON WAY
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-2040
Mailing Address - Country:US
Mailing Address - Phone:559-455-4065
Mailing Address - Fax:770-666-9102
Practice Address - Street 1:24451 HEALTH CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3689
Practice Address - Country:US
Practice Address - Phone:949-452-3573
Practice Address - Fax:949-352-3573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0022882Medicaid
CAZZZ73447ZMedicaid
CAZZZ74694ZMedicaid
CAZZZ14198ZOtherBLUE SHIELD
CAZZZ14199ZOtherBLUE SHIELD
CAZZZ73447ZOtherBLUE SHIELD
CAZZZ14200ZOtherBLUE SHIELD
CAZZZ14199ZOtherBLUE SHIELD
CAZZZ74694ZMedicaid
CAHW168Medicare PIN
CAGR0022882Medicaid