Provider Demographics
NPI:1013962067
Name:TOWER IMAGING MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:TOWER IMAGING MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-549-3030
Mailing Address - Street 1:DEPT LA 21559
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1559
Mailing Address - Country:US
Mailing Address - Phone:888-727-1073
Mailing Address - Fax:866-752-2240
Practice Address - Street 1:2202 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5706
Practice Address - Country:US
Practice Address - Phone:310-264-9000
Practice Address - Fax:310-264-9004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0056083Medicaid
CAZZZ05808ZOtherBLUE SHIELD
CAGR0056081Medicaid
CAZZZ09295ZOtherBLUE SHIELD
CAZZZ64302ZOtherBLUE SHIELD
CAGR0056084Medicaid
CAGR0056086Medicaid
CAZZZ59119ZOtherBLUE SHIELD
CAGR0056085Medicaid
CAZZZ07585ZOtherBLUE SHIELD
CACQ2521Medicare PIN
CACJ4483Medicare PIN
CAHW11779FMedicare PIN
CAZZZ07585ZOtherBLUE SHIELD
CAHW11779EMedicare PIN
CAGR0056086Medicaid
CAW11779Medicare PIN