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General NPI Number Information
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NPI Number | 1992796643
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Entity Type | Organization
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Legal Business Name | MERCED RADIOLOGY MEDICAL GROUP
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Dates
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Enumeration Date | 11/02/2005
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Last Update Date | 10/16/2008
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Provider Practice Location Address
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Address Line | 731 E YOSEMITE AVE SUITE B-170
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City | MERCED
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State | CA
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Zip | 95340-8039
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Country | US
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Telephone | 209-342-2300
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Fax | 209-524-4240
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Provider Business Mailing Address
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Address Line | 4301 NORTHSTAR WAY
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City | MODESTO
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State | CA
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Zip | 95356-9262
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Country | US
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Telephone | 209-342-2300
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Fax | 209-524-4240
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Authorized Official
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Title or Position | DIRECTOR
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Name | MARK A WAGNER
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Credential | DO
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Telephone | 209-342-2300
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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 | 8126
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License Number State | CA
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