Provider Demographics
NPI:1154357531
Name:SOUTH VALLEY IMAGING
Entity type:Organization
Organization Name:SOUTH VALLEY IMAGING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP OF OUTPATIENT SERVICES, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BURTNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-893-2153
Mailing Address - Street 1:PO BOX 16699
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92623-6699
Mailing Address - Country:US
Mailing Address - Phone:818-881-9811
Mailing Address - Fax:818-881-1638
Practice Address - Street 1:18344 CLARK ST
Practice Address - Street 2:SUITE 101
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3505
Practice Address - Country:US
Practice Address - Phone:818-881-9811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2085R0202X
NA261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ90381ZOtherBLUE SHIELD
CAZZZ90381ZOtherBLUE SHIELD