Basic Information
| Provider Information | |||||||||
| NPI: | 1447491501 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTCOM RADIOLOGY MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1633 ERRINGER RD | ||||||||
| Address2: | FIRST FLOOR | ||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930653583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055788300 | ||||||||
| FaxNumber: | 8055783911 | ||||||||
| Practice Location | |||||||||
| Address1: | 1711 W TEMPLE ST | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900265421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134843519 | ||||||||
| FaxNumber: | 2134843592 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2009 | ||||||||
| LastUpdateDate: | 04/02/2009 | ||||||||
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| AuthorizedOfficialLastName: | SCHWARTZ | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2134843519 | ||||||||
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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 | G37428 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0065300 | 05 | CA | MEDICAID |