Healthcare Provider Details

I. General information

NPI: 1356334742
Provider Name (Legal Business Name): MIDCOAST IMAGING MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 E OCEAN AVE
LOMPOC CA
93436-7092
US

IV. Provider business mailing address

PO BOX 7462
ORANGE CA
92863-7462
US

V. Phone/Fax

Practice location:
  • Phone: 805-737-3375
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierCP1084
Identifier TypeOTHER
Identifier State
Identifier IssuerRALROAD MEDICARE
# 2
IdentifierGR0013010
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name: DR. DAVID MCANINCH
Title or Position: DELEGATED OFFICIAL
Credential: MD
Phone: 805-737-3375