Provider Demographics
NPI:1861475352
Name:CENTINELA RADIOLOGY MEDICAL GROUP
Entity type:Organization
Organization Name:CENTINELA RADIOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHAUB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-419-0597
Mailing Address - Street 1:PO BOX 5686
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5686
Mailing Address - Country:US
Mailing Address - Phone:888-598-8819
Mailing Address - Fax:714-571-5055
Practice Address - Street 1:555 E HARDY ST
Practice Address - Street 2:CENTINELA HOSPITAL MEDICAL CENTER
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4011
Practice Address - Country:US
Practice Address - Phone:310-673-4660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CR0166OtherRAILROAD MEDICARE
ZZZ65765ZOtherBLUE SHIELD
CAGR0010880Medicaid
CAGR0010881Medicaid
ZZZ64951ZOtherBLUE SHIELD
ZZZ64952ZOtherBLUE SHIELD
GR0010882OtherCALOPTIMA
GR0010883OtherCALOPTIMA
CAGR0010883Medicaid
CAGR0010882Medicaid
GR0010881OtherCALOPTIMA
ZZZ94679ZOtherBLUE SHIELD
HW8167Medicare PIN