Provider Demographics
NPI:1992747547
Name:MODESTO RADIOLOGICAL MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:MODESTO RADIOLOGICAL MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ZEPPA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-342-5920
Mailing Address - Street 1:1524 MCHENRY AVE STE 420
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4567
Mailing Address - Country:US
Mailing Address - Phone:209-342-5920
Mailing Address - Fax:
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4500
Practice Address - Country:US
Practice Address - Phone:209-342-5920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ78409ZMedicaid
CAGR0043720Medicaid
CAGR0050090Medicaid
CAZZZ02008ZMedicaid
CAZZZ72881ZMedicaid
CAZZZ75541ZMedicaid
CAGR0043723Medicaid
CAGR0043724Medicaid
CAGR0050220Medicaid
CAGR0050221Medicaid
CAGR0043722Medicaid
CAZZZ72867ZMedicaid
CAGR0043723Medicaid
CAZZZ02008ZMedicaid