Provider Demographics
NPI:1639125628
Name:COMMUNITY IMAGING MEDICAL GROUP INC
Entity Type:Organization
Organization Name:COMMUNITY IMAGING MEDICAL GROUP INC
Other - Org Name:DUKE K BAHN MD A PROFESSIONAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-652-5093
Mailing Address - Street 1:DEPT LA 21580
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1580
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:949-263-1639
Practice Address - Street 1:168 N BRENT ST
Practice Address - Street 2:SUITE 401
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2824
Practice Address - Country:US
Practice Address - Phone:805-652-5093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0091501Medicaid
CAGR0091500OtherBLUE SHIELD
CAZZZ03841ZOtherBLUE SHIELD OF CA
CAZZZ04837ZOtherBLUE SHIELD
CAZZZ04836ZOtherBLUE SHIELD
CACJ9683Medicare PIN
CAHW16323Medicare PIN
CAZZZ04836ZOtherBLUE SHIELD