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NPI Code Detail

MEDICARE: NORTH COAST IMAGING RADIOLOGY MEDICAL GROUP, INC.

MEDICARE: NORTH COAST IMAGING RADIOLOGY 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
12085R0204XVascular & Interventional Radiology Physician
22085R0202XDiagnostic Radiology Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1ZZZ40340ZOTHERCABLUE SHIELD
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4ZZZ86398ZOTHERBLUE SHIELD

General Provider Information

NPI Number : 1245283217
Entity Type Code : Organization
Provider Name (Legal Business Name) : NORTH COAST IMAGING RADIOLOGY MEDICAL GROUP, INC.
Provider Business Mailing Address
First Line : 8605 SANTA MONICA BLVD
Second Line : PMB 25192
City : WEST HOLLYWOOD
State : CA
Zip : 90069-4109
Country : US
Telephone Number : 800-880-2973
Fax Number : 951-600-4493
Provider Business Practice Location Address
First Line : 36485 INLAND VALLEY DR
Second Line :
City : WILDOMAR
State : CA
Zip : 92595-9681
Country : US
Telephone Number : 951-677-9713
Fax Number : 951-677-9762
Authorized Official
Title or Position : MANAGER
Name : JASON GARY BECK
Credential :
Telephone Number : 909-347-9340
Provider Enumeration Date : 05/18/2006
Last Update Date : 01/26/2024

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