MEDICARE: PROHEALTH ADVANCED IMAGING MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ66550Z	OTHER	CA	BLUE SHIELD OF CALIFORNIA

General Provider Information

NPI Number	:	1003874702
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROHEALTH ADVANCED IMAGING MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	10767 RIVERSIDE DR
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91602-2324
Country	:	US
Telephone Number	:	818-301-6700
Fax Number	:	818-301-6701

Provider Business Practice Location Address
First Line	:	10767 RIVERSIDE DR
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91602-2324
Country	:	US
Telephone Number	:	818-301-6700
Fax Number	:	818-301-6701

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PAYAM KASHFIAN
Credential	:	M.D.
Telephone Number	:	818-301-6700

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	03/27/2012

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