Provider Demographics
NPI:1013092394
Name:RIVERSIDE RADIOLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:RIVERSIDE RADIOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:MASSEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-788-3400
Mailing Address - Street 1:PO BOX 15648
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95852
Mailing Address - Country:US
Mailing Address - Phone:951-781-2270
Mailing Address - Fax:951-781-2293
Practice Address - Street 1:4500 BROCKTON AVE
Practice Address - Street 2:SUITE 219
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4090
Practice Address - Country:US
Practice Address - Phone:951-276-7550
Practice Address - Fax:951-276-9883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0104280Medicaid
CAGR0104280Medicaid
CACG9918Medicare PIN