Provider Demographics
NPI:1073528469
Name:BACK BAY MEDICAL LLC
Entity Type:Organization
Organization Name:BACK BAY MEDICAL LLC
Other - Org Name:ADVANCED BODY SCAN OF NEWPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-756-8200
Mailing Address - Street 1:20311 SW ACACIA ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-1733
Mailing Address - Country:US
Mailing Address - Phone:949-756-8200
Mailing Address - Fax:949-203-8542
Practice Address - Street 1:20311 SW ACACIA ST
Practice Address - Street 2:SUITE 140
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1733
Practice Address - Country:US
Practice Address - Phone:949-756-8200
Practice Address - Fax:949-203-8542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATG158261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATG158Medicare UPIN