Provider Demographics
NPI:1942607916
Name:ONLINE RADIOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:ONLINE RADIOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D., CFO
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SALEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-786-0801
Mailing Address - Street 1:75 REMITTANCE DR
Mailing Address - Street 2:DEPT. 6620
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-6620
Mailing Address - Country:US
Mailing Address - Phone:888-412-2639
Mailing Address - Fax:
Practice Address - Street 1:115 CORAL ROSE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92603-0177
Practice Address - Country:US
Practice Address - Phone:949-280-8420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA675232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABA460EMedicare PIN