Provider Demographics
NPI:1245391515
Name:ADVANCED RADIOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:ADVANCED RADIOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THANH
Authorized Official - Middle Name:G
Authorized Official - Last Name:PHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-280-0431
Mailing Address - Street 1:7715 GARVEY AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-3003
Mailing Address - Country:US
Mailing Address - Phone:626-280-0431
Mailing Address - Fax:626-280-6840
Practice Address - Street 1:7715 GARVEY AVE
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-3003
Practice Address - Country:US
Practice Address - Phone:626-280-0431
Practice Address - Fax:626-280-6840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC423482085B0100X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Not Answered2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ541862OtherBLUE SHIELD PROVIDER #
CAZZZ541862OtherBLUE SHIELD PROVIDER #
CAB48344Medicare UPIN