Basic Information
Provider Information | |||||||||
NPI: | 1730132275 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SIMI RADIOLOGY AND IMAGING MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4100 GUARDIAN ST STE 205 | ||||||||
Address2: |   | ||||||||
City: | SIMI VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 930636721 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8055225940 | ||||||||
FaxNumber: | 8055226401 | ||||||||
Practice Location | |||||||||
Address1: | 2975 SYCAMORE DR | ||||||||
Address2: |   | ||||||||
City: | SIMI VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 930651201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8059556360 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2006 | ||||||||
LastUpdateDate: | 06/03/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CORDES | ||||||||
AuthorizedOfficialFirstName: | ERIC | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
AuthorizedOfficialTelephone: | 8059556360 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
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 |
ID Information
ID | Type | State | Issuer | Description | GR0050171 | 05 | CA |   | MEDICAID | ZZZ34708Z | 01 |   | BLUE SHIELD | OTHER | CO8000 | 01 |   | RAILROAD MEDICARE | OTHER | GR0050170 | 05 | CA |   | MEDICAID | ZZZ30810Z | 01 |   | BLUE SHIELD | OTHER |