Provider Demographics
NPI:1013951714
Name:NEWPORT CENTER RADIOLOGY ASSOCIATES MEDICAL GROUP INC
Entity Type:Organization
Organization Name:NEWPORT CENTER RADIOLOGY ASSOCIATES MEDICAL GROUP INC
Other - Org Name:NEWPORT IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROOSSIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-574-8200
Mailing Address - Street 1:DEPT LA 21705
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1705
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:949-263-1639
Practice Address - Street 1:360 SAN MIGUEL DR STE 106
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-764-7480
Practice Address - Fax:949-721-9411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ05509ZOtherBLUE SHIELD
CAGR0027850Medicaid
CAZZZ16877ZOtherBLUE SHIELD
CAZZZ13769ZOtherBLUE SHIELD
CAZZZ05509ZOtherBLUE SHIELD
CAW10829AMedicare PIN
CAZZZ16877ZOtherBLUE SHIELD