MEDICARE: BREAST IMAGING RADIOLOGISTS, A MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ13747Z	OTHER	CA	BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104872605
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BREAST IMAGING RADIOLOGISTS, A MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1620
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47706-0022
Country	:	US
Telephone Number	:	562-933-7833
Fax Number	:	562-933-7869

Provider Business Practice Location Address
First Line	:	2810 LONG BEACH BLVD FL 2
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806-1558
Country	:	US
Telephone Number	:	562-933-7833
Fax Number	:	562-933-7869

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	ANGELA SIE
Credential	:	MD
Telephone Number	:	562-933-7833

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	03/04/2024

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