MEDICARE: WEST COAST RADIOLOGY CENTER SOUTH COAST

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	2085B0100X	Body Imaging Physician
2	2085U0001X	Diagnostic Ultrasound Physician
3	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1740429422
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST COAST RADIOLOGY CENTER SOUTH COAST

Provider Business Mailing Address
First Line	:	PO BOX 11924
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92711-1924
Country	:	US
Telephone Number	:	714-835-3709
Fax Number	:	714-836-7034

Provider Business Practice Location Address
First Line	:	2620 S BRISTOL ST
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92704-5727
Country	:	US
Telephone Number	:	714-966-0904
Fax Number	:	714-966-0972

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. MICHAEL L. BLACK
Credential	:	M.D.
Telephone Number	:	714-835-6055

Provider Enumeration Date	:	02/19/2009
Last Update Date	:	06/08/2009

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