Provider Demographics
NPI:1205010709
Name:SAN GABRIEL RADIOLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:SAN GABRIEL RADIOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, PRESIDENT, DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:WHALEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-572-0914
Mailing Address - Street 1:555 N GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-1202
Mailing Address - Country:US
Mailing Address - Phone:626-572-0914
Mailing Address - Fax:626-572-0914
Practice Address - Street 1:555 N GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1202
Practice Address - Country:US
Practice Address - Phone:626-572-0914
Practice Address - Fax:626-572-0914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC334762085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW22403OtherMEDICARE PTAN