Basic Information
| Provider Information | |||||||||
| NPI: | 1720032204 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTURY RADIOLOGY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 190 | ||||||||
| Address2: | |||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930620190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055225940 | ||||||||
| FaxNumber: | 8055226401 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907121419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626026810 | ||||||||
| FaxNumber: | 5626303594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 02/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | FIELDS | ||||||||
| AuthorizedOfficialFirstName: | MARVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5626026810 | ||||||||
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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 | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0013841 | 05 | CA | MEDICAID | CE7194 | 01 | RAILROAD MEDICARE | OTHER | GR0013840 | 05 | CA | MEDICAID | ZZZ76869Z | 05 | CA | MEDICAID | ZZZ76869Z | 01 | BLUE SHIELD | OTHER | ZZZ13785Z | 01 | BLUE SHIELD | OTHER | ZZZ15759Z | 01 | BLUE SHIELD | OTHER | ZZZ13968Z | 01 | BLUE SHIELD | OTHER |