Provider Demographics
NPI:1104872605
Name:BREAST IMAGING RADIOLOGISTS, A MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:BREAST IMAGING RADIOLOGISTS, A MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-933-7833
Mailing Address - Street 1:PO BOX 1620
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-0022
Mailing Address - Country:US
Mailing Address - Phone:562-933-7833
Mailing Address - Fax:562-933-7869
Practice Address - Street 1:2810 LONG BEACH BLVD FL 2
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1558
Practice Address - Country:US
Practice Address - Phone:562-933-7833
Practice Address - Fax:562-933-7869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ13747ZOtherBLUE SHIELD
CAGR0103100Medicaid
CAGR0103100Medicaid
CAZZZ13747ZOtherBLUE SHIELD