1013962067 NPI number — TOWER IMAGING MEDICAL GROUP, INC

Table of content: (NPI 1013962067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013962067 NPI number — TOWER IMAGING MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOWER IMAGING MEDICAL GROUP, INC
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:
1013962067
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT LA 21559
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91185-1559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-727-1073
Provider Business Mailing Address Fax Number:
866-752-2240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2202 WILSHIRE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA MONICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90403-5706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-264-9000
Provider Business Practice Location Address Fax Number:
310-264-9004
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROTH
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
323-549-3030

Provider Taxonomy Codes

  • Taxonomy code: 2085N0904X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0056083 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ05808Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0056081 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ09295Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ64302Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0056084 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0056086 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ59119Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0056085 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ07585Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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