1205010709 NPI number — SAN GABRIEL RADIOLOGY MEDICAL GROUP

Table of content: (NPI 1205010709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205010709 NPI number — SAN GABRIEL RADIOLOGY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN GABRIEL RADIOLOGY MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205010709
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 N GARFIELD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTEREY PARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91754-1202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-572-0914
Provider Business Mailing Address Fax Number:
626-572-0914

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 N GARFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTEREY PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91754-1202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-572-0914
Provider Business Practice Location Address Fax Number:
626-572-0914
Provider Enumeration Date:
12/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WHALEN
Authorized Official First Name:
SEAN
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
CEO, PRESIDENT, DIRECTOR
Authorized Official Telephone Number:
626-572-0914

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  C33476 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: W22403 . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com