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NPI Code Detail

MEDICARE: PLACERVILLE RADIOLOGY MEDICAL GROUP INC

MEDICARE: PLACERVILLE RADIOLOGY MEDICAL GROUP INC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12085R0202XDiagnostic Radiology Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1700847621
Entity Type Code : Organization
Provider Name (Legal Business Name) : PLACERVILLE RADIOLOGY MEDICAL GROUP INC
Provider Business Mailing Address
First Line : PO BOX 1650
Second Line :
City : EVANSVILLE
State : IN
Zip : 47706-0051
Country : US
Telephone Number : 530-626-2613
Fax Number : 530-344-5434
Provider Business Practice Location Address
First Line : 1100 MARSHALL WAY
Second Line :
City : PLACERVILLE
State : CA
Zip : 95667-6533
Country : US
Telephone Number : 530-626-2613
Fax Number : 530-344-5434
Authorized Official
Title or Position : PRESIDENT
Name : ANIETIE OKON
Credential : MD
Telephone Number : 530-626-2613
Provider Enumeration Date : 03/30/2006
Last Update Date : 03/17/2025

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