Provider Demographics
NPI:1689627317
Name:LA JOLLA RADIOLOGY MEDICAL GROUP - DIAGNOSIS, INC.
Entity Type:Organization
Organization Name:LA JOLLA RADIOLOGY MEDICAL GROUP - DIAGNOSIS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:HB
Authorized Official - Last Name:MCCREIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-454-4235
Mailing Address - Street 1:P.O. BOX 2570
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91319-2570
Mailing Address - Country:US
Mailing Address - Phone:800-386-8024
Mailing Address - Fax:805-375-8900
Practice Address - Street 1:10150 SORRENTO VALLEY RD
Practice Address - Street 2:SUITE 320
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1635
Practice Address - Country:US
Practice Address - Phone:858-454-4235
Practice Address - Fax:858-454-4644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2009-06-22
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
CAGR0006796Medicaid
ZZZ00191ZOtherBLUE SHIELD
ZZZ00872ZOtherBLUE SHIELD
ZZZ71703ZOtherBLUE SHIELD
ZZZ23443ZOtherBLUE SHIELD
ZZZ777070ZOtherBLUE SHIELD
ZZZ00192ZOtherBLUE SHIELD
CAGR0006799Medicaid
ZZZ00873ZOtherBLUE SHIELD
CAZZZ71703ZMedicaid
ZZZ73863ZOtherBLUE SHIELD
CAZZZ73863ZMedicaid
ZZZ777070ZOtherBLUE SHIELD
CAZZZ73863ZMedicaid
CAGR0006799Medicaid
ZZZ71703ZOtherBLUE SHIELD
ZZZ73863ZOtherBLUE SHIELD