Provider Demographics
NPI:1902008642
Name:ADVANCED MEMORIAL IMAGING GROUP, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ADVANCED MEMORIAL IMAGING GROUP, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAGDISH
Authorized Official - Middle Name:M
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-278-9363
Mailing Address - Street 1:17868 US HIGHWAY 18
Mailing Address - Street 2:#358
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1267
Mailing Address - Country:US
Mailing Address - Phone:760-946-5177
Mailing Address - Fax:760-946-5133
Practice Address - Street 1:301 W BASTANCHURY RD
Practice Address - Street 2:#130
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3419
Practice Address - Country:US
Practice Address - Phone:714-278-9363
Practice Address - Fax:714-278-9364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW21387Medicare PIN