Provider Demographics
NPI:1720069891
Name:NORTHERN CALIFORNIA RADIATION THERAPISTS & ONCOLOGISTS MEDICAL GROUP I
Entity type:Organization
Organization Name:NORTHERN CALIFORNIA RADIATION THERAPISTS & ONCOLOGISTS MEDICAL GROUP I
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-342-2300
Mailing Address - Street 1:450 GLASS LN STE C
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9287
Mailing Address - Country:US
Mailing Address - Phone:209-342-2300
Mailing Address - Fax:209-524-4240
Practice Address - Street 1:2333 BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-1925
Practice Address - Country:US
Practice Address - Phone:209-342-2300
Practice Address - Fax:209-524-4240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1028292085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ27539ZOtherBLUE SHIELD
CAGR0054561Medicaid
CAZZZ86312ZOtherBLUE SHIELD
CAZZZ75605ZOtherBLUE SHIELD
CAZZZ75605ZMedicaid
CAZZZ86312ZMedicaid
CAZZZ77840ZOtherBLUE SHIELD
CAZZZ77840ZMedicaid
CAZZZ77840ZMedicare PIN
CAZZZ27539ZMedicare PIN
CAZZZ86312ZMedicaid
CAZZZ27539ZOtherBLUE SHIELD