Healthcare Provider Details

I. General information

NPI: 1043258676
Provider Name (Legal Business Name): ST MARYS RADIOLOGY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 ATLANTIC AVE SUITE 105
LONG BEACH CA
90813-3408
US

IV. Provider business mailing address

1045 ATLANTIC AVE SUITE 105
LONG BEACH CA
90813-3408
US

V. Phone/Fax

Practice location:
  • Phone: 562-437-3833
  • Fax: 562-624-0741
Mailing address:
  • Phone: 562-437-3833
  • Fax: 562-624-0741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. GREGORY T VANLEY
Title or Position: PARTNER
Credential: M.D.
Phone: 562-437-3833