Healthcare Provider Details

I. General information

NPI: 1164760823
Provider Name (Legal Business Name): BEVERLY RADIOLOGY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2013
Last Update Date: 01/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15243 VANOWEN ST
VAN NUYS CA
91405-3605
US

IV. Provider business mailing address

15243 VANOWEN ST
VAN NUYS CA
91405-3605
US

V. Phone/Fax

Practice location:
  • Phone: 818-782-6110
  • Fax: 818-782-7354
Mailing address:
  • Phone: 818-782-6110
  • Fax: 818-782-7354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberFNP 43686
License Number StateCA

VIII. Authorized Official

Name: HOWARD G. BERGER
Title or Position: CEO & PRESIDENT
Credential: M.D.
Phone: 310-445-2800