Healthcare Provider Details

I. General information

NPI: 1700252467
Provider Name (Legal Business Name): RIVERSIDE RADIOLOGY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2015
Last Update Date: 08/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30700 E SUNSET DR S
REDLANDS CA
92373-7448
US

IV. Provider business mailing address

PO BOX 511412
LOS ANGELES CA
90051-7967
US

V. Phone/Fax

Practice location:
  • Phone: 310-717-0360
  • Fax: 770-666-9102
Mailing address:
  • Phone: 877-441-9002
  • Fax: 559-455-4018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA112768
License Number StateCA

VIII. Authorized Official

Name: DR. DONALD MASSEE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 951-781-2273