NPIMap

Organization Active NPI

Medical Imaging Center of Southern California

  • Diagnostic Radiology Physician
  • Santa Monica, CA
National Provider Identifier
1700907433
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
License
W13479 Issued in CA
Legal business name
MEDICAL IMAGING CENTER OF SOUTHERN CALIFORNIA
Practice address
2827 Wilshire Blvd
Santa Monica, CA 90403-4801
Phone
(310) 829-9788
Fax
(310) 453-1576
NPI assigned
Apr 2, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dairzette Layne
Title
Billing Manager
Phone
(310) 829-9788

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2085R0202X W13479 CA Primary

Addresses

Primary practice location

2827 Wilshire Blvd
Santa Monica, CA 90403-4801

Mailing address

2827 Wilshire Blvd
Santa Monica, CA 90403-4801
Phone (310) 829-9788

Other identifiers 2

IdentifierTypeStateIssuer
123448OtherCAMAMMOGRAPHY CERTIFICATION
ZZZ15575ZOtherCABLUE SHIELD OF CA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050427000588 CA Part B Supplier - Clinic/Group Practice 2961306469 Receives reassigned benefits from 16 practitioners
Practice locations: Santa Monica, CA

National Provider Directory

National Provider Directory

Locations

8727 Beverly Blvd
West Hollywood, CA 90048
Phone (310) 829-9788

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1175472000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1700907433",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2827 WILSHIRE BLVD",
            "city": "SANTA MONICA",
            "state": "CA",
            "postal_code": "904034801",
            "telephone_number": "310-829-9788",
            "fax_number": "310-453-1576"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2827 WILSHIRE BLVD",
            "city": "SANTA MONICA",
            "state": "CA",
            "postal_code": "904034801",
            "telephone_number": "310-829-9788",
            "fax_number": "310-453-1576"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEDICAL IMAGING CENTER OF SOUTHERN CALIFORNIA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-02",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "LAYNE",
        "authorized_official_first_name": "DAIRZETTE",
        "authorized_official_title_or_position": "BILLING MANAGER",
        "authorized_official_telephone_number": "310-829-9788"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "CA",
            "license": "W13479",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MAMMOGRAPHY CERTIFICATION",
            "identifier": "123448",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD OF CA",
            "identifier": "ZZZ15575Z",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Santa Monica, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.