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General NPI Number Information
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NPI Number | 1235535220
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Entity Type | Organization
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Legal Business Name | ONLINE RADIOLOGY MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 11/18/2014
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Last Update Date | 11/18/2014
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Provider Practice Location Address
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Address Line | 315 CALLE PESCADOR
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City | SAN CLEMENTE
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State | CA
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Zip | 92672-2206
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Country | US
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Telephone | 949-388-4014
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Fax |
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Provider Business Mailing Address
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Address Line | 75 REMITTANCE DR DEPT. 6620
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City | CHICAGO
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State | IL
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Zip | 60675-6620
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Country | US
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Telephone | 888-412-2639
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Fax |
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Authorized Official
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Title or Position | M.D., CFO
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Name | SAMUEL SALEN
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Credential |
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Telephone | 951-786-0801
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | G81806
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License Number State | CA
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