Healthcare Provider Details

I. General information

NPI: 1730133893
Provider Name (Legal Business Name): MODESTO ADVANCED DIAGNOSTIC IMAGING MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 E COOLIDGE AVE
MODESTO CA
95350-4504
US

IV. Provider business mailing address

1516 COTNER AVE
LOS ANGELES CA
90025-3303
US

V. Phone/Fax

Practice location:
  • Phone: 209-524-6800
  • Fax: 209-524-1286
Mailing address:
  • Phone: 310-445-2951
  • Fax: 310-479-1459

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: HOWARD G BERGER
Title or Position: PRESIDENT
Credential: MD
Phone: 310-445-2800