Basic Information
| Provider Information | |||||||||
| NPI: | 1992797070 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GLENDORA RADIOLOGICAL ASSOC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 414 E SAN BERNARDINO RD | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917231704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004753698 | ||||||||
| FaxNumber: | 6263312313 | ||||||||
| Practice Location | |||||||||
| Address1: | 414 E SAN BERNARDINO RD | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917231704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263395464 | ||||||||
| FaxNumber: | 6263312313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 10/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | UNDERWOOD | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6263395464 | ||||||||
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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 | CP3326 | 01 | CA | RAIL ROAD MEDICARE GRP # | OTHER | ZZZ35484Z | 01 | CA | BLUE SHIELD PROVIDER | OTHER | ZZZ14525Z | 01 | CA | BLUE SHIELD PROVIDER | OTHER | GR0011500 | 05 | CA | MEDICAID | GR0011502 | 05 | CA | MEDICAID |