MEDICARE: BLUEBEAM RADIOLOGY PC

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	A92712	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	EK119A	OTHER	CA	MEDICARE PTAN

General Provider Information

NPI Number	:	1508184334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEBEAM RADIOLOGY PC

Provider Business Mailing Address
First Line	:	PO BOX 10662
Second Line	:
City	:	FULLERTON
State	:	CA
Zip	:	92838-6662
Country	:	US
Telephone Number	:	800-922-6151
Fax Number	:

Provider Business Practice Location Address
First Line	:	3902 EL CAJON BLVD STE A
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-1016
Country	:	US
Telephone Number	:	800-922-6151
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	VIKRAM M HATTI
Credential	:	M.D.
Telephone Number	:	800-922-6151

Provider Enumeration Date	:	05/04/2010
Last Update Date	:	07/21/2022

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