Basic Information
| Provider Information | |||||||||
| NPI: | 1982605432 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE RADIOLOGY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15648 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958520648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517812270 | ||||||||
| FaxNumber: | 9517812293 | ||||||||
| Practice Location | |||||||||
| Address1: | 18300 US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923072206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602422311 | ||||||||
| FaxNumber: | 7602423306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | MASSEE | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9517812270 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0104280 | 05 | CA | MEDICAID |