Provider Demographics
NPI:1326104605
Name:PACIFIC SHORES RADIOLOGY MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:PACIFIC SHORES RADIOLOGY MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:POH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-792-3914
Mailing Address - Street 1:PO BOX 3129
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90510-3129
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:855-898-4055
Practice Address - Street 1:1025 S ANAHEIM BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-5806
Practice Address - Country:US
Practice Address - Phone:714-563-2813
Practice Address - Fax:714-502-2691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60583174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1326104605Medicaid
CA1326104605Medicaid