Provider Demographics
NPI:1104300763
Name:SAINT GORGE RADIOLOGY
Entity type:Organization
Organization Name:SAINT GORGE RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DMYTRO
Authorized Official - Middle Name:
Authorized Official - Last Name:MALAKHOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-698-4448
Mailing Address - Street 1:12610 GLENOAKS BLVD STE 10
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-4783
Mailing Address - Country:US
Mailing Address - Phone:818-698-4448
Mailing Address - Fax:818-698-4449
Practice Address - Street 1:12610 GLENOAKS BLVD STE 10
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-4783
Practice Address - Country:US
Practice Address - Phone:818-698-4448
Practice Address - Fax:818-698-4449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty