Organization
SOUTH COAST RADIOLOGICAL MEDICAL GROUP INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RICHARD JONATHAN WASLEY M.D. (CEO/PRESIDENT)
(949) 452-3573
Entity
Organization
Contact information
Practice address
24451 HEALTH CENTER DRIVE, LAGUNA HILLS, CA 92653-3689
(949) 452-3573
(949) 352-3573
Mailing address
5110 E. CLINTON WAY, FRESNO, CA 93727-2040
(559) 455-4065
(770) 666-9102
Taxonomy
Speciality
Code
Description
License number
State
207U00000X
Nuclear Medicine Physician
—
—
2085N0700X
Neuroradiology Physician
—
—
2085R0202X
Diagnostic Radiology Physician
Primary
—
—
2085R0204X
Vascular & Interventional Radiology Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GR0022882
—
CA
01
—
ZZZ14198Z
BLUE SHIELD
CA
01
—
ZZZ14199Z
BLUE SHIELD
CA
01
—
ZZZ14200Z
BLUE SHIELD
CA
01
—
ZZZ73447Z
BLUE SHIELD
CA
05
—
ZZZ73447Z
—
CA
05
—
ZZZ74694Z
—
CA
Enumeration date
05/16/2006
Last updated
09/16/2022
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