Basic Information
| Provider Information | |||||||||
| NPI: | 1013962067 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TOWER IMAGING MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT LA 21559 | ||||||||
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| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911851559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887271073 | ||||||||
| FaxNumber: | 8667522240 | ||||||||
| Practice Location | |||||||||
| Address1: | 2202 WILSHIRE BLVD | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904035706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102649000 | ||||||||
| FaxNumber: | 3102649004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 02/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | ROTH | ||||||||
| AuthorizedOfficialFirstName: | GERALD | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3235493030 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0056083 | 05 | CA | MEDICAID | ZZZ05808Z | 01 | CA | BLUE SHIELD | OTHER | GR0056081 | 05 | CA | MEDICAID | ZZZ09295Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ64302Z | 01 | CA | BLUE SHIELD | OTHER | GR0056084 | 05 | CA | MEDICAID | GR0056086 | 05 | CA | MEDICAID | ZZZ59119Z | 01 | CA | BLUE SHIELD | OTHER | GR0056085 | 05 | CA | MEDICAID | ZZZ07585Z | 01 | CA | BLUE SHIELD | OTHER |