Healthcare Provider Details

I. General information

NPI: 1396759726
Provider Name (Legal Business Name): GLENDALE RADIOLOGY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 WILSON TER 1420 S CENTRAL AVE
GLENDALE CA
91206-4007
US

IV. Provider business mailing address

625 N MARYLAND AVE
GLENDALE CA
91206-2245
US

V. Phone/Fax

Practice location:
  • Phone: 818-247-2095
  • Fax: 818-247-1863
Mailing address:
  • Phone: 818-247-2095
  • Fax: 818-247-1863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES M. LILLEY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 818-247-2095