MEDICARE: COMMUNITY IMAGING 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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	GR0091500	OTHER	CA	BLUE SHIELD
3	ZZZ03841Z	OTHER	CA	BLUE SHIELD OF CA
4	ZZZ04837Z	OTHER	CA	BLUE SHIELD
5	ZZZ04836Z	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1639125628
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY IMAGING MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	DEPT LA 21580
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91185-1580
Country	:	US
Telephone Number	:	949-263-8620
Fax Number	:	949-263-1639

Provider Business Practice Location Address
First Line	:	168 N BRENT ST
Second Line	:	SUITE 401
City	:	VENTURA
State	:	CA
Zip	:	93003-2824
Country	:	US
Telephone Number	:	805-652-5093
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHARLES NORTH
Credential	:	MD
Telephone Number	:	805-652-5093

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	10/29/2009

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