Provider Demographics
NPI:1396774022
Name:SOCAL MR SITE MANAGEMENT, INC.
Entity type:Organization
Organization Name:SOCAL MR SITE MANAGEMENT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position: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:310-445-2800
Mailing Address - Street 1:1037 N GRAND AVE PMB 203
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-2048
Mailing Address - Country:US
Mailing Address - Phone:310-445-2800
Mailing Address - Fax:310-445-2816
Practice Address - Street 1:740 E ARROW HWY
Practice Address - Street 2:SUITE A
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-2144
Practice Address - Country:US
Practice Address - Phone:626-966-1580
Practice Address - Fax:626-967-7821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0059840Medicaid
CAGR0090660Medicaid
CAGR0090661Medicaid
CAZZZ19215ZOtherBLUE SHIELD
CAZZZ23491ZOtherBLUE SHIELD
CAZZZ45829ZOtherBLUE SHIELD
CAGR0090661Medicaid
CAZZZ19215ZOtherBLUE SHIELD
CATD048Medicare ID - Type Unspecified