1841720059 NPI number — BEVERLY RADIOLOGY MEDICAL GROUP

Table of content: (NPI 1841720059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841720059 NPI number — BEVERLY RADIOLOGY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEVERLY RADIOLOGY MEDICAL GROUP
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:
1841720059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1160D PITTSFORD VICTOR RD FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PITTSFORD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14534-3818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-218-8001
Provider Business Mailing Address Fax Number:
585-218-8099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8540 S SEPULVEDA BLVD STE 111
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90045-3810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-645-9050
Provider Business Practice Location Address Fax Number:
310-216-2683
Provider Enumeration Date:
06/20/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BERGER
Authorized Official First Name:
HOWARD
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
CEO & PRESIDENT
Authorized Official Telephone Number:
310-445-2800

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  2760275 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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