Provider Demographics
NPI:1962456129
Name:BEVERLY RADIOLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:BEVERLY RADIOLOGY MEDICAL GROUP
Other - Org Name:BURBANK ADVANCED IMAGING CENTER MED GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:BERGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-445-2800
Mailing Address - Street 1:PO BOX 240086
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-9186
Mailing Address - Country:US
Mailing Address - Phone:626-966-1580
Mailing Address - Fax:626-967-7821
Practice Address - Street 1:10101 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602-2517
Practice Address - Country:US
Practice Address - Phone:818-762-2626
Practice Address - Fax:818-762-0288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03078ZOtherBLUE SHIELD
CAZZZ03078ZOtherBLUE SHIELD