1366567463 NPI number — DELTA RADIOLOGY MEDICAL GROUP, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366567463 NPI number — DELTA RADIOLOGY MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DELTA RADIOLOGY MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366567463
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 15498
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95851-0498
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-455-4000
Provider Business Mailing Address Fax Number:
559-455-4007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
845 JACKSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94133-4851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-677-2325
Provider Business Practice Location Address Fax Number:
415-677-2444
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDBERG
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
209-334-4416

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0006150 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com