Provider Demographics
NPI:1992796643
Name:MERCED RADIOLOGY MEDICAL GROUP
Entity type:Organization
Organization Name:MERCED RADIOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:209-342-2300
Mailing Address - Street 1:4301 NORTHSTAR WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9262
Mailing Address - Country:US
Mailing Address - Phone:209-342-2300
Mailing Address - Fax:209-524-4240
Practice Address - Street 1:731 E YOSEMITE AVE
Practice Address - Street 2:SUITE B-170
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-8039
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:2005-11-02
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0005283Medicaid
CAGR0005286Medicaid
CAGR0005289Medicaid
CAGR0005282Medicaid
CAGR0005287Medicaid
CAZZZ25145ZOtherBLUE SHIELD
CAGR0005280Medicaid
CAGR0005281Medicaid
CAGR0005285Medicaid
CAYYY49735YMedicare PIN
CAYYY49682YMedicare PIN
CAGR0005283Medicaid
CAZZZ25226ZMedicare PIN
CAZZZ25888ZMedicare PIN
CAYYY49679YMedicare PIN
CAGR0005282Medicaid
CAGR0005281Medicaid
CAGR0005280Medicaid