Basic Information
| Provider Information | |||||||||
| NPI: | 1225084296 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC IMAGING MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6102 | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949486102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158843404 | ||||||||
| FaxNumber: | 4158831836 | ||||||||
| Practice Location | |||||||||
| Address1: | 747 52ND ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946091809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104283410 | ||||||||
| FaxNumber: | 5106013968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 04/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | COHEN | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5104283410 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085P0229X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0094540 | 05 | CA | MEDICAID | ZZZ09080Z | 01 | CA | BLUE SHIELD OF CA | OTHER | 100504919 | 05 | NV | MEDICAID |