Healthcare Provider Details

I. General information

NPI: 1588788152
Provider Name (Legal Business Name): ST JUDE RADIOLOGY MEDICAL GRP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 N HARBOR BLVD
FULLERTON CA
92835-3801
US

IV. Provider business mailing address

PO BOX 4505
WOODLAND HILLS CA
91365-4505
US

V. Phone/Fax

Practice location:
  • Phone: 714-992-3978
  • Fax: 714-992-3298
Mailing address:
  • Phone: 805-375-8800
  • Fax: 805-375-8900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. ROBERT C MORTEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 714-992-3978