Provider Demographics
NPI:1235296880
Name:I V RADIOLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:I V RADIOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:RAPP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-721-8943
Mailing Address - Street 1:PO BOX 3246
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92244-3246
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 WEST LEGION ROAD
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-7780
Practice Address - Country:US
Practice Address - Phone:760-352-9808
Practice Address - Fax:760-352-0751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT30342FOtherM CAL IP FACILITY ID #
CAGR0015900Medicaid
CAZZT40342FOtherM CAL OP FACILITY ID #
CAZZT30342FOtherM CAL IP FACILITY ID #