1780823997 NPI number — SMI IMAGING, LLC

Table of content: (NPI 1780823997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780823997 NPI number — SMI IMAGING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMI IMAGING, LLC
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:
SIMONMED IMAGING - MOUNTAIN VIEW
Provider Other Organization Name Type Code:
5
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:
1780823997
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7368
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92863-7368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-571-5000
Provider Business Mailing Address Fax Number:
571-571-5055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9201 E MOUNTAIN VIEW RD
Provider Second Line Business Practice Location Address:
SUITE 137
Provider Business Practice Location Address City Name:
SCOTTSDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85258-5199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-614-8555
Provider Business Practice Location Address Fax Number:
480-614-8666
Provider Enumeration Date:
02/11/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SIMON
Authorized Official First Name:
HOWARD
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
480-264-2400

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  OTC4696 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00811052 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 472759 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".