Basic Information
Provider Information | |||||||||
NPI: | 1689890444 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SANTA ROSA IMAGING MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1516 COTNER AVE | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900253303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3104452952 | ||||||||
FaxNumber: | 3104791459 | ||||||||
Practice Location | |||||||||
Address1: | 3536 MENDOCINO AVE STE 280 | ||||||||
Address2: |   | ||||||||
City: | SANTA ROSA | ||||||||
State: | CA | ||||||||
PostalCode: | 954033634 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7075798226 | ||||||||
FaxNumber: | 7075791457 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/18/2007 | ||||||||
LastUpdateDate: | 11/02/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BERGER | ||||||||
AuthorizedOfficialFirstName: | HOWARD | ||||||||
AuthorizedOfficialMiddleName: | G. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3104452800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.