Provider Demographics
NPI:1831173905
Name:MEMRAD MEDICAL GROUP INC
Entity type:Organization
Organization Name:MEMRAD MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-590-7400
Mailing Address - Street 1:100 OCEANGATE
Mailing Address - Street 2:STE 1000
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802
Mailing Address - Country:US
Mailing Address - Phone:562-590-7400
Mailing Address - Fax:562-590-7452
Practice Address - Street 1:100 OCEANGATE
Practice Address - Street 2:STE 1000
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802
Practice Address - Country:US
Practice Address - Phone:562-590-7400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GR0023359OtherMEDI-CAL
GR0023355OtherMEDI-CAL
GR0023352OtherMEDI-CAL
GR0023356OtherMEDI-CAL
GR0023358OtherMEDI-CAL
ZZZ74966ZOtherMEDI-CAL
ZZZ77516ZOtherMEDI-CAL
GR0023351OtherMEDI-CAL
GR0023357OtherMEDI-CAL
ZZZ27107ZOtherBLUE SHIELD
ZZZ74966ZOtherMEDI-CAL
HW1576CMedicare ID - Type Unspecified
HW1576EMedicare ID - Type Unspecified
HW1576FMedicare ID - Type Unspecified
GR0023355OtherMEDI-CAL
HW1576DMedicare ID - Type Unspecified
HW1576IMedicare ID - Type Unspecified
W1576AMedicare ID - Type Unspecified
GR0023351OtherMEDI-CAL
ZZZ77516ZOtherMEDI-CAL