Basic Information
| Provider Information | |||||||||
| NPI: | 1346298528 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UC REGENTS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UCI RADIOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 513255 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900513255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144568068 | ||||||||
| FaxNumber: | 7144562979 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 THE CITY DR S | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144568068 | ||||||||
| FaxNumber: | 7144562979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 02/24/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KOCH | ||||||||
| AuthorizedOfficialFirstName: | DEBI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7144568068 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335V00000X | N | Suppliers | Portable X-Ray Supplier | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | ZZZP3012Z | 01 | CA | BLUE SHIELD GROUP # | OTHER | CD6546 | 01 | CA | RAILROAD MEDICARE GROUP | OTHER | GR0077110 | 01 | CA | MEDI-CAL GROUP # | OTHER | HW13931 | 01 | MEDICARE GROUP # | OTHER | ZZZ22566Z | 01 | CA | BLUE SHIELD GROUP # | OTHER |