=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205010709
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN GABRIEL RADIOLOGY MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2007
-----------------------------------------------------
Last Update Date | 03/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 N GARFIELD AVE
-----------------------------------------------------
City | MONTEREY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91754-1202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-572-0914
-----------------------------------------------------
Fax | 626-572-0914
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 N GARFIELD AVE
-----------------------------------------------------
City | MONTEREY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91754-1202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-572-0914
-----------------------------------------------------
Fax | 626-572-0914
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO, PRESIDENT, DIRECTOR
-----------------------------------------------------
Name | SEAN PATRICK WHALEN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 626-572-0914
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | C33476
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------