Basic Information
| Provider Information | |||||||||
| NPI: | 1710963418 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RAD-IMAGE MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 OCEANGATE | ||||||||
| Address2: | STE 1000 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625907400 | ||||||||
| FaxNumber: | 5625907452 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 ATLANTIC AVE | ||||||||
| Address2: | LONG BEACH MEMORIAL MEDICAL CENTER | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908061737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629332000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | JAGDISH | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5625907400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207U00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | 2085N0700X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ64951Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ64952Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ94679Z | 01 | CA | BLUE SHIELD | OTHER | GR0010881 | 01 | CA | MEDICAL | OTHER | GR0020883 | 01 | CA | MEDICAL | OTHER | GR0010882 | 01 | CA | MEDICAL | OTHER |