Provider Demographics
NPI:1700261765
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:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:MASSEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-455-4065
Mailing Address - Street 1:1660 CHICAGO AVE
Mailing Address - Street 2:M-9
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2068
Mailing Address - Country:US
Mailing Address - Phone:559-455-4065
Mailing Address - Fax:770-666-9102
Practice Address - Street 1:400 WARREN DR
Practice Address - Street 2:APT. 4
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94131-1075
Practice Address - Country:US
Practice Address - Phone:559-455-4065
Practice Address - Fax:770-666-9102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1127682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1194979856Medicaid