1861475352 NPI number — CENTINELA RADIOLOGY MEDICAL GROUP

Table of content: (NPI 1861475352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861475352 NPI number — CENTINELA RADIOLOGY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTINELA 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:
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:
1861475352
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5686
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:
92863-5686
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-598-8819
Provider Business Mailing Address Fax Number:
714-571-5055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 E HARDY ST
Provider Second Line Business Practice Location Address:
CENTINELA HOSPITAL MEDICAL CENTER
Provider Business Practice Location Address City Name:
INGLEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90301-4011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-673-4660
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SHAUB
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
310-419-0597

Provider Taxonomy Codes

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

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

  • Identifier: CR0166 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: ZZZ65765Z . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: GR0010880 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0010881 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ64951Z . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: ZZZ64952Z . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: GR0010882 . This is a "CALOPTIMA" identifier . This identifiers is of the category "OTHER".
  • Identifier: GR0010883 . This is a "CALOPTIMA" identifier . This identifiers is of the category "OTHER".
  • Identifier: GR0010883 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0010882 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0010881 . This is a "CALOPTIMA" identifier . This identifiers is of the category "OTHER".
  • Identifier: ZZZ94679Z . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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