Provider Demographics
NPI:1902814759
Name:GLENDALE DIAGNOSTIC IMAGING NETWORK MEDICAL OFFICE INC
Entity Type:Organization
Organization Name:GLENDALE DIAGNOSTIC IMAGING NETWORK MEDICAL OFFICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:J
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-548-8333
Mailing Address - Street 1:800 S CENTRAL AVE
Mailing Address - Street 2:100B
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-4370
Mailing Address - Country:US
Mailing Address - Phone:818-548-8333
Mailing Address - Fax:818-548-7888
Practice Address - Street 1:800 S CENTRAL AVE
Practice Address - Street 2:100B
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-4370
Practice Address - Country:US
Practice Address - Phone:818-548-8333
Practice Address - Fax:818-548-7888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG846872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19100Medicare ID - Type UnspecifiedGLENDALE DIAGNOSTIC IMAGI