Healthcare Provider Details

I. General information

NPI: 1497708002
Provider Name (Legal Business Name): BROADWAY IMAGING MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 08/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 NORTH GLENDALE AVE
GLENDALE CA
91206
US

IV. Provider business mailing address

140 NORTH GLENDALE AVE
GLENDALE CA
91206
US

V. Phone/Fax

Practice location:
  • Phone: 818-548-0022
  • Fax: 818-548-8385
Mailing address:
  • Phone: 818-548-0022
  • Fax: 818-548-8385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Internal Medicine Physician
License NumberA71010
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA71010
License Number StateCA

VIII. Authorized Official

Name: HOSAM M MOUSTAFA
Title or Position: PRESIDENT
Credential: MD
Phone: 818-548-0022