MEDICARE: WESTERN IMAGING, MARINA DEL REY

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528153665
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN IMAGING, MARINA DEL REY

Provider Business Mailing Address
First Line	:	9808 VENICE BLVD
Second Line	:	2ND FLOOR
City	:	CULVER CITY
State	:	CA
Zip	:	90232
Country	:	US
Telephone Number	:	310-836-4700
Fax Number	:	310-836-6925

Provider Business Practice Location Address
First Line	:	4640 ADMIRALTY WAY
Second Line	:	SUITE 102
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-6621
Country	:	US
Telephone Number	:	310-836-4700
Fax Number	:	310-836-6925

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. MATTHEW J LOTYSCH
Credential	:	M.D.
Telephone Number	:	31083964700

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	08/30/2007

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