MEDICARE: ADVANCED DIAGNOSTIC & MANAGEMENT

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	261QR0208X	Mobile Radiology Clinic/Center		CA

General Provider Information

NPI Number	:	1285783639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED DIAGNOSTIC & MANAGEMENT

Provider Business Mailing Address
First Line	:	6210 WILSHIRE BLVD STE 205
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-5124
Country	:	US
Telephone Number	:	310-770-9528
Fax Number	:

Provider Business Practice Location Address
First Line	:	6210 WILSHIRE BLVD STE 205
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-5124
Country	:	US
Telephone Number	:	310-770-9528
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TEIMUR AZ URUSHADZE
Credential	:	PHD
Telephone Number	:	323-954-8999

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	09/28/2007

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