Provider Demographics
NPI:1376698548
Name:AEGIS PEDIATRIC IMAGING MEDICAL GROUP
Entity Type:Organization
Organization Name:AEGIS PEDIATRIC IMAGING MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-391-2014
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 1:116 W LIME AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-2841
Practice Address - Country:US
Practice Address - Phone:626-391-2014
Practice Address - Fax:626-915-1209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Single Specialty