Basic Information
| Provider Information | |||||||||
| NPI: | 1043378136 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN DIEGO DIAGNOSTIC RADIOLOGY MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | SAN DIEGO IMAGING MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23540 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921933540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585650950 | ||||||||
| FaxNumber: | 8582441100 | ||||||||
| Practice Location | |||||||||
| Address1: | 7910 FROST ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921232771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586345900 | ||||||||
| FaxNumber: | 8586345990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 03/23/2017 | ||||||||
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| AuthorizedOfficialLastName: | CHEN | ||||||||
| AuthorizedOfficialFirstName: | NORMAN | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 8585650950 | ||||||||
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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 | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QM1200X | N | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) | 261QP3300X | N | Ambulatory Health Care Facilities | Clinic/Center | Pain | 261QR0206X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0083816 | 05 | CA | MEDICAID |