=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013962067
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOWER IMAGING MEDICAL GROUP, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2006
-----------------------------------------------------
Last Update Date | 02/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2202 WILSHIRE BLVD
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90403-5706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-264-9000
-----------------------------------------------------
Fax | 310-264-9004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | DEPT LA 21559
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91185-1559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-727-1073
-----------------------------------------------------
Fax | 866-752-2240
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GERALD M. ROTH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 323-549-3030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085N0904X
-----------------------------------------------------
Taxonomy Name | Nuclear Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------