Provider Demographics
NPI:1184981409
Name:BEVERLY RADIOLOGY MEDICAL GROUP
Entity type:Organization
Organization Name:BEVERLY RADIOLOGY MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO & 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:310-445-4800
Mailing Address - Street 1:15651 IMPERIAL HWY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1628
Mailing Address - Country:US
Mailing Address - Phone:562-947-3870
Mailing Address - Fax:
Practice Address - Street 1:15651 IMPERIAL HWY
Practice Address - Street 2:SUITE 103
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1628
Practice Address - Country:US
Practice Address - Phone:562-947-3870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16629Medicare PIN