1750514998 NPI number — SMI IMAGING, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750514998 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:
Provider Other Organization Name Type Code:
6
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:
1750514998
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:
714-571-5055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20830 N TATUM BLVD
Provider Second Line Business Practice Location Address:
SUITE 190
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85050-7256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-306-7900
Provider Business Practice Location Address Fax Number:
480-306-7910
Provider Enumeration Date:
09/03/2009

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  OTC4686 , 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: 470462 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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