Provider Demographics
NPI:1689635971
Name:FULLY OPEN MRI OF RANCHO BERNARDO LLC DBA POMERADO IMAGING
Entity Type:Organization
Organization Name:FULLY OPEN MRI OF RANCHO BERNARDO LLC DBA POMERADO IMAGING
Other - Org Name:POMERADO IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:D
Authorized Official - Last Name:POLANSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-520-8500
Mailing Address - Street 1:PO BOX 460875
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92046-0875
Mailing Address - Country:US
Mailing Address - Phone:760-520-8500
Mailing Address - Fax:760-520-8523
Practice Address - Street 1:15725 POMERADO RD
Practice Address - Street 2:SUITE 109
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2068
Practice Address - Country:US
Practice Address - Phone:858-485-6094
Practice Address - Fax:858-485-6059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3184261QM1200X, 261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATP048Medicare ID - Type Unspecified
CATP048Medicare PIN