1205867017 NPI number — SAN DIEGO DIAGNOSTIC RADIOLOGY MEDICAL GROUP INC

Table of content: (NPI 1205867017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205867017 NPI number — SAN DIEGO DIAGNOSTIC RADIOLOGY MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN DIEGO DIAGNOSTIC RADIOLOGY 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:
1205867017
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23540
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92193-3540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-565-0950
Provider Business Mailing Address Fax Number:
858-244-1100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3020 CHILDRENS WAY
Provider Second Line Business Practice Location Address:
CHILDREN'S HOSPITAL AND HEALTH CENTER
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92123-4223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-966-7769
Provider Business Practice Location Address Fax Number:
858-966-8568
Provider Enumeration Date:
07/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHEN
Authorized Official First Name:
NORMAN
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
858-565-0950

Provider Taxonomy Codes

  • Taxonomy code: 207U00000X , with the licence number:  B1982005164 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207UN0901X , with the licence number: B1982005164 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207UN0902X , with the licence number: B1982005164 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085B0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0904X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085P0229X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: B1982005164 , registered in the state of CA ; 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" .
  • Taxonomy code: 2085R0203X , with the licence number: B1982005164 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085U0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X , with the licence number: B1982005164 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: B1982005164 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GR0083810 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".