MEDICARE: SAN DIEGO DIAGNOSTIC RADIOLOGY MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	2085R0202X	Diagnostic Radiology Physician
2	2085B0100X	Body Imaging Physician
3	2085R0204X	Vascular & Interventional Radiology Physician
4	2085U0001X	Diagnostic Ultrasound Physician
5	2085N0700X	Neuroradiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548297088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN DIEGO DIAGNOSTIC RADIOLOGY MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	PO BOX 23540
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92193-3540
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	765 MEDICAL CENTER CT
Second Line	:	SAN DIEGO IMAGING - CHULA VISTA
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-6600
Country	:	US
Telephone Number	:	619-397-6577
Fax Number	:	619-397-5182

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT
Name	:	RICHARD W PADELFORD
Credential	:
Telephone Number	:	858-565-0950

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	03/22/2017

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