Organization
FULLERTON RADIOLOGY MEDICAL GROUP, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MICHAEL G CHAN D.O. (PRESIDENT)
(714) 526-2241
Entity
Organization
Contact information
Practice address
5528 E LA PALMA AVE STE 4A, ANAHEIM, CA 92807-2115
(714) 993-2000
(714) 524-4216
Mailing address
3350 E BIRCH ST, SUITE 105, BREA, CA 92821-6264
(714) 992-0850
(714) 526-8271
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GR0006731
—
CA
05
—
GR0006736
—
CA
05
—
GR0006737
—
CA
05
—
GR0006738
—
CA
01
—
ZZZ642972
BLUE SHIELD OF CALIF
CA
01
—
ZZZ74739Z
BLUE SHIELD OF CALIF
CA
05
—
ZZZ74739Z
—
CA
01
—
ZZZ75588Z
BLUE SHIELD OF CALIF
CA
Enumeration date
03/20/2006
Last updated
09/05/2024
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