Basic Information
| Provider Information | |||||||||
| NPI: | 1871549899 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PUEBLO RADIOLOGY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT LA 21613 | ||||||||
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| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911851613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492638620 | ||||||||
| FaxNumber: | 9492631639 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 W PUEBLO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931053805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056827744 | ||||||||
| FaxNumber: | 8056823321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 05/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | HARTER | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8056827984 | ||||||||
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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 | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0011030 | 05 | CA | MEDICAID | GR0011034 | 05 | CA | MEDICAID | GR0011038 | 05 | CA | MEDICAID | GR001103A | 05 | CA | MEDICAID | GR001103B | 05 | CA | MEDICAID | ZZZ73471Z | 05 | CA | MEDICAID | GR001103C | 05 | CA | MEDICAID | GR0011035 | 05 | CA | MEDICAID | GR0011039 | 05 | CA | MEDICAID | GR0011037 | 05 | CA | MEDICAID | ZZZ50521Y | 01 | CA | BS | OTHER |