Basic Information
| Provider Information | |||||||||
| NPI: | 1265485015 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINK RADIOLOGIC IMAGING MEDICAL ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 190 | ||||||||
| Address2: | |||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930620190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055225940 | ||||||||
| FaxNumber: | 8055226401 | ||||||||
| Practice Location | |||||||||
| Address1: | 8670 WILSHIRE BLVD STE 101 | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902112930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103582100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 10/08/2013 | ||||||||
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| AuthorizedOfficialLastName: | MINK | ||||||||
| AuthorizedOfficialFirstName: | JERROLD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3103582100 | ||||||||
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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 | ZZZ06391Z | 01 | BLUE SHIELD | OTHER | ZZZ66023Z | 01 | BLUE SHIELD | OTHER | DA6633 | 01 | RAILROAD MEDICARE | OTHER | ZZZ77048Z | 01 | BLUE SHIELD | OTHER |