Healthcare Provider Details

I. General information

NPI: 1013962067
Provider Name (Legal Business Name): TOWER IMAGING MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 02/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 WILSHIRE BLVD
SANTA MONICA CA
90403-5706
US

IV. Provider business mailing address

DEPT LA 21559
PASADENA CA
91185-1559
US

V. Phone/Fax

Practice location:
  • Phone: 310-264-9000
  • Fax: 310-264-9004
Mailing address:
  • Phone: 888-727-1073
  • Fax: 866-752-2240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: GERALD M. ROTH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 323-549-3030