Provider Demographics
NPI:1013948652
Name:SAN VICENTE RADIOLOGY MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:SAN VICENTE RADIOLOGY MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ZHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:TROSTENETSKAYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-653-7300
Mailing Address - Street 1:151 N SAN VICENTE BLVD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2323
Mailing Address - Country:US
Mailing Address - Phone:323-653-7300
Mailing Address - Fax:323-653-7399
Practice Address - Street 1:151 N SAN VICENTE BLVD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2323
Practice Address - Country:US
Practice Address - Phone:323-653-7300
Practice Address - Fax:323-653-7399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0205XAllopathic & Osteopathic PhysiciansRadiologyRadiological PhysicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14721Medicare PIN