Provider Demographics
NPI:1972655058
Name:HUMBOLDT RADIOLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:HUMBOLDT RADIOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:COBINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-445-5431
Mailing Address - Street 1:PO BOX 6428
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95502-6428
Mailing Address - Country:US
Mailing Address - Phone:707-445-5431
Mailing Address - Fax:707-445-3710
Practice Address - Street 1:2200 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3215
Practice Address - Country:US
Practice Address - Phone:707-445-8121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0015540Medicaid
CN3976OtherRAILROAD MEDICARE
CN3976OtherRAILROAD MEDICARE