MEDICARE: ON-LINE RADIOLOGY MEDICAL GROUP INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center		CA
2	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1710158498
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ON-LINE RADIOLOGY MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	PO BOX 5594
Second Line	:
City	:	CAROL STREAM
State	:	IL
Zip	:	60197-5594
Country	:	US
Telephone Number	:	866-509-8452
Fax Number	:	508-273-1241

Provider Business Practice Location Address
First Line	:	1770 IOWA AVE
Second Line	:	SUITE 280
City	:	RIVERSIDE
State	:	CA
Zip	:	92507-2430
Country	:	US
Telephone Number	:	800-848-5876
Fax Number	:	855-226-5960

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. SAMUEL SALEN
Credential	:	MD
Telephone Number	:	951-786-0801

Provider Enumeration Date	:	03/20/2008
Last Update Date	:	12/05/2018

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