Healthcare Provider Details

I. General information

NPI: 1710158498
Provider Name (Legal Business Name): ON-LINE RADIOLOGY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1770 IOWA AVE SUITE 280
RIVERSIDE CA
92507-2430
US

IV. Provider business mailing address

PO BOX 5594
CAROL STREAM IL
60197-5594
US

V. Phone/Fax

Practice location:
  • Phone: 800-848-5876
  • Fax: 855-226-5960
Mailing address:
  • Phone: 866-509-8452
  • Fax: 508-273-1241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMUEL SALEN
Title or Position: DIRECTOR
Credential: MD
Phone: 951-786-0801