Provider Demographics
NPI:1952468506
Name:I V RADIOLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:I V RADIOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER OF IMPERIAL VALLEY RADIOLOG
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HADORN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-339-7241
Mailing Address - Street 1:PO BOX 889
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91365-0889
Mailing Address - Country:US
Mailing Address - Phone:805-375-8800
Mailing Address - Fax:805-375-8900
Practice Address - Street 1:1415 ROSS AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4306
Practice Address - Country:US
Practice Address - Phone:760-339-7241
Practice Address - Fax:760-339-7249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0015902Medicaid
CAZZT30045FOtherMCAL IP FACILITY ID#
CAZZT40045FOtherMCAL OP FACILITY ID #
CAGR0015902Medicaid