=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275587842
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOWER PET IMAGING CENTER, A MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 465 N ROXBURY DR
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90210-4230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-975-1500
-----------------------------------------------------
Fax | 310-975-1517
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 240086
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90024-9186
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-445-2800
-----------------------------------------------------
Fax | 310-445-2816
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HOWARD G BERGER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 310-445-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------