Healthcare Provider Details

I. General information

NPI: 1881198604
Provider Name (Legal Business Name): MODESTO RADIOLOGICAL MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 03/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 CHELSHURST WAY
SPRING TX
77379-3247
US

IV. Provider business mailing address

1524 MCHENRY AVE STE 430
MODESTO CA
95350-4567
US

V. Phone/Fax

Practice location:
  • Phone: 559-455-4009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: MARK E MOORE
Title or Position: CFO
Credential:
Phone: 209-577-4444