Basic Information
| Provider Information | |||||||||
| NPI: | 1154357531 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH VALLEY IMAGING | ||||||||
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| OtherOrganizationName: | SOUTH VALLEY IMAGING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16699 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926236699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188819811 | ||||||||
| FaxNumber: | 8188811638 | ||||||||
| Practice Location | |||||||||
| Address1: | 18344 CLARK ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913563505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188819811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
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| AuthorizedOfficialLastName: | BURTNETT | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | KYLE | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP OF OUTPATIENT SERVICES, TENET | ||||||||
| AuthorizedOfficialTelephone: | 4698932153 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | NA | N | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ90381Z | 01 | CA | BLUE SHIELD | OTHER |