Healthcare Provider Details

I. General information

NPI: 1326461708
Provider Name (Legal Business Name): REDWOOD RADIOLOGY GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2014
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 SOTOYOME ST
SANTA ROSA CA
95405-4823
US

IV. Provider business mailing address

PO BOX 5651
ORANGE CA
92863-5651
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-4062
  • Fax: 707-525-4095
Mailing address:
  • Phone: 714-571-5000
  • Fax: 714-571-5055

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: FRANK E MODIC
Title or Position: PRESIDENT
Credential: M.D.
Phone: 707-546-4062