Provider Demographics
NPI:1144571076
Name:SAN DIEGO DIAGNOSTIC RADIOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:SAN DIEGO DIAGNOSTIC RADIOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/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:
Mailing Address - Fax:
Practice Address - Street 1:15615 POMERADO RD
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2405
Practice Address - Country:US
Practice Address - Phone:858-613-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-02
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HW529Medicare PIN