Provider Demographics
NPI:1063411460
Name:PALM IMAGING INSTITUTE, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:PALM IMAGING INSTITUTE, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DONALDSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:909-882-2266
Mailing Address - Street 1:399 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4815
Mailing Address - Country:US
Mailing Address - Phone:909-882-2266
Mailing Address - Fax:909-881-7593
Practice Address - Street 1:399 E 21ST ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4815
Practice Address - Country:US
Practice Address - Phone:909-882-2266
Practice Address - Fax:909-881-7593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55682207XS0114X
CAA84930207XX0005X
CAPT 10673225100000X
CAPA20947363AS0400X
CA289262085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0063970Medicaid
CAGR0063970Medicaid
CA5976640001Medicare NSC