Provider Demographics
NPI:1093243404
Name:BEVERLY RADIOLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:BEVERLY RADIOLOGY MEDICAL GROUP
Other - Org Name:NORTHRIDGE DIAGNOSTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO & PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:BERGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-445-2800
Mailing Address - Street 1:1516 COTNER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3303
Mailing Address - Country:US
Mailing Address - Phone:310-445-2800
Mailing Address - Fax:
Practice Address - Street 1:8227 RESEDA BLVD
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-1247
Practice Address - Country:US
Practice Address - Phone:818-773-6500
Practice Address - Fax:818-701-5936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4624822085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty