Provider Demographics
NPI:1558317883
Name:LOMA LINDA UNIVERSITY RADIOLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:LOMA LINDA UNIVERSITY RADIOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO LLU RADIOLOGY MEDICAL GROUP INC
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-558-3012
Mailing Address - Street 1:PO BOX 30959
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90030-0959
Mailing Address - Country:US
Mailing Address - Phone:909-558-3012
Mailing Address - Fax:909-558-3292
Practice Address - Street 1:25333 BARTON ROAD
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354
Practice Address - Country:US
Practice Address - Phone:909-558-3012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0011161Medicaid
CAGR0011161Medicaid