Provider Demographics
NPI:1205304433
Name:NEWPORT CENTER RADIOLOGY MEDICAL GROUP INC.
Entity type:Organization
Organization Name:NEWPORT CENTER RADIOLOGY MEDICAL GROUP INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:949-263-8620
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:714-727-1007
Practice Address - Street 1:15000 KENSINGTON PARK DR
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92782-1830
Practice Address - Country:US
Practice Address - Phone:714-477-8340
Practice Address - Fax:714-477-8341
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEWPORT CENTER RADIOLOGY MEDICAL GROUP INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-06
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology