Basic Information
| Provider Information | |||||||||
| NPI: | 1336263946 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORCAL IMAGING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1516 COTNER AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900253303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104452951 | ||||||||
| FaxNumber: | 3104791459 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 WASHINGTON AVE | ||||||||
| Address2: | SUITE # 120 | ||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945775996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103517734 | ||||||||
| FaxNumber: | 5103517742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 05/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | BERGER | ||||||||
| AuthorizedOfficialFirstName: | HOWARD | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3104452800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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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 | 1336263946 | 05 | CA | MEDICAID |