Provider Demographics
NPI:1265485015
Name:MINK RADIOLOGIC IMAGING MEDICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:MINK RADIOLOGIC IMAGING MEDICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JERROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:MINK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-358-2100
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93062-0190
Mailing Address - Country:US
Mailing Address - Phone:805-522-5940
Mailing Address - Fax:805-522-6401
Practice Address - Street 1:8670 WILSHIRE BLVD STE 101
Practice Address - Street 2:SUITE 101
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2930
Practice Address - Country:US
Practice Address - Phone:310-358-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ06391ZOtherBLUE SHIELD
ZZZ66023ZOtherBLUE SHIELD
DA6633OtherRAILROAD MEDICARE
ZZZ77048ZOtherBLUE SHIELD
DA6633OtherRAILROAD MEDICARE
W16124Medicare ID - Type Unspecified