Healthcare Provider Details

I. General information

NPI: 1750498093
Provider Name (Legal Business Name): IMAGING HEALTHCARE SPECIALISTS MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6256 GREENWICH DR SUITE 150
SAN DIEGO CA
92122-5941
US

IV. Provider business mailing address

FILE 1317 1801 W OLYMPIC BLVD
PASADENA CA
91199-1317
US

V. Phone/Fax

Practice location:
  • Phone: 866-558-4320
  • Fax: 619-294-8399
Mailing address:
  • Phone: 888-927-8018
  • Fax: 800-508-4751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: THOMAS D CLEARY
Title or Position: PRESIDENT & CEO
Credential:
Phone: 866-558-4320