Basic Information
Provider Information | |||||||||
NPI: | 1376698548 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AEGIS PEDIATRIC IMAGING MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 190 | ||||||||
Address2: |   | ||||||||
City: | SIMI VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 930620190 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8055225940 | ||||||||
FaxNumber: | 8055226401 | ||||||||
Practice Location | |||||||||
Address1: | 116 W LIME AVE | ||||||||
Address2: |   | ||||||||
City: | MONROVIA | ||||||||
State: | CA | ||||||||
PostalCode: | 910162841 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6263912014 | ||||||||
FaxNumber: | 6269151209 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/25/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NELSON | ||||||||
AuthorizedOfficialFirstName: | MARVIN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
AuthorizedOfficialTelephone: | 6263912014 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085P0229X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
No ID Information.