MEDICARE: MODESTO RADIOLOGICAL 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	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1740654912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODESTO RADIOLOGICAL MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	1524 MCHENRY AVE
Second Line	:	SUITE 430
City	:	MODESTO
State	:	CA
Zip	:	95350-4500
Country	:	US
Telephone Number	:	559-455-4009
Fax Number	:	916-533-0313

Provider Business Practice Location Address
First Line	:	6496 DEER HOLLOW DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95120-1634
Country	:	US
Telephone Number	:	559-455-4009
Fax Number	:	916-533-0313

Authorized Official
Title or Position	:	CFO/COO
Name	:	MARK MOORE
Credential	:
Telephone Number	:	209-342-5946

Provider Enumeration Date	:	11/25/2015
Last Update Date	:	01/27/2016

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