MEDICARE: SOUTH COAST RADIOLOGICAL MEDICAL GROUP INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207U00000X	Nuclear Medicine Physician
2	2085N0700X	Neuroradiology Physician
3	2085R0204X	Vascular & Interventional Radiology Physician
4	2085R0202X	Diagnostic Radiology 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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	ZZZ14198Z	OTHER	CA	BLUE SHIELD
5	ZZZ14199Z	OTHER	CA	BLUE SHIELD
6	ZZZ73447Z	OTHER	CA	BLUE SHIELD
7	ZZZ14200Z	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1902858384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH COAST RADIOLOGICAL MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	5110 E. CLINTON WAY
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93727-2040
Country	:	US
Telephone Number	:	559-455-4065
Fax Number	:	770-666-9102

Provider Business Practice Location Address
First Line	:	24451 HEALTH CENTER DRIVE
Second Line	:
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-3689
Country	:	US
Telephone Number	:	949-452-3573
Fax Number	:	949-352-3573

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	RICHARD JONATHAN WASLEY
Credential	:	M.D.
Telephone Number	:	949-452-3573

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	09/16/2022

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