Provider Demographics
NPI:1124054994
Name:THURMOND-FEDERAL RADIOLOGY AND IMAGING MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:THURMOND-FEDERAL RADIOLOGY AND IMAGING MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:AUBREY
Authorized Official - Last Name:FEDERAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-467-1000
Mailing Address - Street 1:546 E PINE ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5525
Mailing Address - Country:US
Mailing Address - Phone:209-467-1000
Mailing Address - Fax:209-467-7335
Practice Address - Street 1:546 E PINE ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5525
Practice Address - Country:US
Practice Address - Phone:209-467-1000
Practice Address - Fax:209-467-7335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA36098Medicare UPIN
CAZZZ97078ZMedicare PIN