Healthcare Provider Details

I. General information

NPI: 1861451858
Provider Name (Legal Business Name): FULLERTON RADIOLOGY MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5528 E LA PALMA AVE STE 4A
ANAHEIM CA
92807-2115
US

IV. Provider business mailing address

3350 E BIRCH ST SUITE 105
BREA CA
92821-6264
US

V. Phone/Fax

Practice location:
  • Phone: 714-993-2000
  • Fax: 714-524-4216
Mailing address:
  • Phone: 714-992-0850
  • Fax: 714-526-8271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL G CHAN
Title or Position: PRESIDENT
Credential: D.O.
Phone: 714-526-2241