Basic Information
Provider Information | |||||||||
NPI: | 1942245022 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IMAGING CONSULTANTS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 18201 VON KARMAN AVE STE 600 | ||||||||
Address2: |   | ||||||||
City: | IRVINE | ||||||||
State: | CA | ||||||||
PostalCode: | 926121176 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9492425592 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 275 SANDWICH ST | ||||||||
Address2: |   | ||||||||
City: | PLYMOUTH | ||||||||
State: | MA | ||||||||
PostalCode: | 023602183 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5087462000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2006 | ||||||||
LastUpdateDate: | 05/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLOOM | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | A. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9785522600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: | 05/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X |   | MA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QM1200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
ID | Type | State | Issuer | Description | 1529790 | 05 | MA |   | MEDICAID | 346646400 | 01 | MA | U.S. DEPT OF LABOR OWCP | OTHER | 036769 | 01 | MA | BCBS | OTHER | 626264 | 01 | MA | HARVARD PILGRIM HEALTH CA | OTHER | 0008850 | 01 | MA | NEIGHBORHOOD HEALTH PLAN | OTHER | 13270 | 01 | MA | HEALTH NEW ENGLAND | OTHER | 36984 | 01 | MA | FALLON | OTHER | 713587 | 01 | MA | TUFTS HEALTH PLANS/SECURE | OTHER |