Healthcare Provider Details

I. General information

NPI: 1306854294
Provider Name (Legal Business Name): RADIOLOGY MEDICAL GROUP OF SANTA CRUZ COUNTY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 B GREEN VALLEY ROAD
FREEDOM CA
95019-3110
US

IV. Provider business mailing address

1661 SOQUEL DRIVE BUILDING G
SANTA CRUZ CA
95065-1709
US

V. Phone/Fax

Practice location:
  • Phone: 831-724-2236
  • Fax: 831-724-8440
Mailing address:
  • Phone: 831-476-1542
  • Fax: 831-464-8977

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: KENNETH E AVERILL JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 831-476-1542