1952468506 NPI number — I V RADIOLOGY MEDICAL GROUP

Table of content: (NPI 1952468506)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952468506 NPI number — I V RADIOLOGY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
I V 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:
1952468506
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 889
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODLAND HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91365-0889
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-375-8800
Provider Business Mailing Address Fax Number:
805-375-8900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1415 ROSS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-4306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-339-7241
Provider Business Practice Location Address Fax Number:
760-339-7249
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HADORN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PARTNER OF IMPERIAL VALLEY RADIOLOG
Authorized Official Telephone Number:
760-339-7241

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: GR0015902 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZT30045F . This is a "MCAL IP FACILITY ID#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZT40045F . This is a "MCAL OP FACILITY ID #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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