Provider Demographics
NPI:1740837442
Name:RADIANCE MEDICAL GROUP
Entity type:Organization
Organization Name:RADIANCE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BORGIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:267-809-1799
Mailing Address - Street 1:1229 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-4837
Mailing Address - Country:US
Mailing Address - Phone:215-792-4212
Mailing Address - Fax:267-361-0666
Practice Address - Street 1:1229 S 6TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-4837
Practice Address - Country:US
Practice Address - Phone:215-792-4212
Practice Address - Fax:267-361-0666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD427968OtherPA