Basic Information
| Provider Information | |||||||||
| NPI: | 1063676195 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOLANO REGIONAL MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 254978 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958654978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004700071 | ||||||||
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| Practice Location | |||||||||
| Address1: | 770 MASON ST | ||||||||
| Address2: | |||||||||
| City: | VACAVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956884646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004700071 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2008 | ||||||||
| LastUpdateDate: | 07/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | RUSHFORD | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7074342049 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOLANO REGIONAL MEDICAL GROUP INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0206X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0059866 | 05 | CA | MEDICAID |