Provider Demographics
NPI:1508813619
Name:SOUTH VALLEY RADIOLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SOUTH VALLEY RADIOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:GRITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-726-6480
Mailing Address - Street 1:FILE 1261
Mailing Address - Street 2:1801 W. OLYMPIC BOULEVARD
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91199-0665
Mailing Address - Country:US
Mailing Address - Phone:877-406-2916
Mailing Address - Fax:800-656-0592
Practice Address - Street 1:18344 CLARK ST
Practice Address - Street 2:SUITE 101
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3505
Practice Address - Country:US
Practice Address - Phone:818-881-9811
Practice Address - Fax:818-881-1638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ65212ZOtherBLUE SHIELD
CAZZZ65202ZOtherBLUE SHIELD
CAZZZ65301ZOtherBLUE SHIELD
CAGR0092560Medicaid
CAGR0092562Medicaid
CAZZZ80581ZMedicaid
CAZZZ65198ZOtherBLUE SHIELD
CAZZZ65200ZOtherBLUE SHIELD
CAZZZ65201ZOtherBLUE SHIELD
CAZZZ65198ZOtherBLUE SHIELD
CAGR0092562Medicaid
CAZZZ65200ZOtherBLUE SHIELD