Healthcare Provider Details

I. General information

NPI: 1013951714
Provider Name (Legal Business Name): NEWPORT CENTER RADIOLOGY ASSOCIATES MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 SAN MIGUEL DR STE 106
NEWPORT BEACH CA
92660
US

IV. Provider business mailing address

DEPT LA 21705
PASADENA CA
91185-1705
US

V. Phone/Fax

Practice location:
  • Phone: 949-764-7480
  • Fax: 949-721-9411
Mailing address:
  • Phone: 949-263-8620
  • Fax: 949-263-1639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL C ROOSSIN
Title or Position: PRESIDENT
Credential: MD
Phone: 949-574-8200