Basic Information
| Provider Information | |||||||||
| NPI: | 1891859674 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHARP AND CHILDREN'S MRI CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23326 | ||||||||
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| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921933326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585650950 | ||||||||
| FaxNumber: | 8582441100 | ||||||||
| Practice Location | |||||||||
| Address1: | 7910 FROST ST | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921232771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589394550 | ||||||||
| FaxNumber: | 8589394596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 11/05/2015 | ||||||||
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| AuthorizedOfficialLastName: | LOW | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | N. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8585650950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
| ID | Type | State | Issuer | Description | GR0083817 | 05 | CA | MEDICAID |