1750498093 NPI number — IMAGING HEALTHCARE SPECIALISTS MEDICAL GROUP, INC.

Table of content: (NPI 1750498093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750498093 NPI number — IMAGING HEALTHCARE SPECIALISTS MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMAGING HEALTHCARE SPECIALISTS 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:
1750498093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
FILE 1317 1801 W OLYMPIC BLVD
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:
91199-1317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-927-8018
Provider Business Mailing Address Fax Number:
800-508-4751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6256 GREENWICH DR
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92122-5941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-558-4320
Provider Business Practice Location Address Fax Number:
619-294-8399
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLEARY
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
866-558-4320

Provider Taxonomy Codes

  • Taxonomy code: 207U00000X ; 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: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GR0103681 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0103684 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR010368A , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR010368C , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0103683 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0103680 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0103685 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0103687 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR010368B , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0103686 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0103688 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0103689 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0103682 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR010368D , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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