Provider Demographics
NPI:1053541128
Name:WEST COAST RADIOLOGY CENTER - ANAHEIM
Entity type:Organization
Organization Name:WEST COAST RADIOLOGY CENTER - ANAHEIM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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 1:1085 N HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-2417
Mailing Address - Country:US
Mailing Address - Phone:714-300-0703
Mailing Address - Fax:714-300-0704
Practice Address - Street 1:1085 N HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2417
Practice Address - Country:US
Practice Address - Phone:714-300-0703
Practice Address - Fax:714-300-0704
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST COAST RADIOLOGY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-22
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
W10646OtherMEDICARE PTAN