MEDICARE: MEDICAL DIAGNOSIS PORTABLE X-RAY & EKG SERVICES INC. MDX

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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	TG092	OTHER		MEDICARE(ULTRASOUND)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	630000095	OTHER		PALMETTO GBARAILROAD MED
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609868488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL DIAGNOSIS PORTABLE X-RAY & EKG SERVICES INC. MDX

Provider Business Mailing Address
First Line	:	4139 MAMMOTH AVE
Second Line	:
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91423-4323
Country	:	US
Telephone Number	:	818-281-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	5627 SEPULVEDA BLVD
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91411-2920
Country	:	US
Telephone Number	:	818-281-4000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BIALIK VAHDAT BENJAMIN
Credential	:	CRT
Telephone Number	:	818-281-4000

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	05/20/2022

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