Basic Information
| Provider Information | |||||||||
| NPI: | 1235185158 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOMA LINDA UNIVERSITY RADIOLOGY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30959 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900300959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095583012 | ||||||||
| FaxNumber: | 9095583292 | ||||||||
| Practice Location | |||||||||
| Address1: | 11370 ANDERSON ST | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095583012 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 11/20/2007 | ||||||||
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| AuthorizedOfficialLastName: | KIRK | ||||||||
| AuthorizedOfficialFirstName: | GERALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO LLU RADIOLOGY MEDICAL GROUP INC | ||||||||
| AuthorizedOfficialTelephone: | 9095583012 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | GR0011163 | 05 | CA | MEDICAID |