Provider Demographics
NPI:1043378136
Name:SAN DIEGO DIAGNOSTIC RADIOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:SAN DIEGO DIAGNOSTIC RADIOLOGY MEDICAL GROUP, INC.
Other - Org Name:SAN DIEGO IMAGING MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-565-0950
Mailing Address - Street 1:PO BOX 23540
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-3540
Mailing Address - Country:US
Mailing Address - Phone:858-565-0950
Mailing Address - Fax:858-244-1100
Practice Address - Street 1:7910 FROST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2771
Practice Address - Country:US
Practice Address - Phone:858-634-5900
Practice Address - Fax:858-634-5990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083816Medicaid
CAGR0083816Medicaid