Provider Demographics
NPI:1740429422
Name:WEST COAST RADIOLOGY CENTER SOUTH COAST
Entity type:Organization
Organization Name:WEST COAST RADIOLOGY CENTER SOUTH COAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-835-6055
Mailing Address - Street 1:PO BOX 11924
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92711-1924
Mailing Address - Country:US
Mailing Address - Phone:714-835-3709
Mailing Address - Fax:714-836-7034
Practice Address - Street 1:2620 S BRISTOL ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-5727
Practice Address - Country:US
Practice Address - Phone:714-966-0904
Practice Address - Fax:714-966-0972
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST COAST RADIOLOGY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-19
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW10646Medicare UPIN