Healthcare Provider Details

I. General information

NPI: 1518165638
Provider Name (Legal Business Name): EAGLE IMAGING MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 08/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 S BATAVIA ST STE. 103
ORANGE CA
92868-3936
US

IV. Provider business mailing address

PO BOX 5989
ORANGE CA
92863-5989
US

V. Phone/Fax

Practice location:
  • Phone: 714-538-6731
  • Fax: 714-771-8369
Mailing address:
  • Phone: 714-571-5000
  • Fax: 714-571-5055

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: BARRY HABERMAN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 714-571-5000