Basic Information
| Provider Information | |||||||||
| NPI: | 1083875884 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST VINCENT RADIOLOGICAL MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19130 | ||||||||
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| City: | NEWBURY PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913199130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134847901 | ||||||||
| FaxNumber: | 2133530325 | ||||||||
| Practice Location | |||||||||
| Address1: | 2131 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900571901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134847901 | ||||||||
| FaxNumber: | 2133530325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2008 | ||||||||
| LastUpdateDate: | 08/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | WALUCH | ||||||||
| AuthorizedOfficialFirstName: | VICTOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2134847901 | ||||||||
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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 | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ77454Z | 05 | CA | MEDICAID |