Basic Information
| Provider Information | |||||||||
| NPI: | 1003866914 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED IMAGING OF SOUTH BAY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT LA 21552 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911851552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492638620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4101 TORRANCE BLVD | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905034607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103035750 | ||||||||
| FaxNumber: | 3103035709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | STEIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | Z | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3107073590 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0102980 | 05 | CA | MEDICAID | ZZZ13651Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ13660Z | 01 | CA | BLUE SHIELD | OTHER | GR0102981 | 05 | CA | MEDICAID | ZZZ13652Z | 01 | CA | BLUE SHIELD | OTHER |