Basic Information
| Provider Information | |||||||||
| NPI: | 1205304433 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEWPORT CENTER RADIOLOGY MEDICAL GROUP INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TUSTIN IMAGING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT LA 21705 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911851705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492638620 | ||||||||
| FaxNumber: | 7147271007 | ||||||||
| Practice Location | |||||||||
| Address1: | 15000 KENSINGTON PARK DR | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927821830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144778340 | ||||||||
| FaxNumber: | 7144778341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2018 | ||||||||
| LastUpdateDate: | 11/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | ROOSSIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9492638620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NEWPORT CENTER RADIOLOGY MEDICAL GROUP INC. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.