Provider Demographics
NPI:1396759726
Name:GLENDALE RADIOLOGY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:GLENDALE RADIOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:LILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-247-2095
Mailing Address - Street 1:625 N MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-2245
Mailing Address - Country:US
Mailing Address - Phone:818-247-2095
Mailing Address - Fax:818-247-1863
Practice Address - Street 1:1509 WILSON TER
Practice Address - Street 2:1420 S CENTRAL AVE
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4007
Practice Address - Country:US
Practice Address - Phone:818-247-2095
Practice Address - Fax:818-247-1863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ75635ZMedicaid
CAHW15226Medicare ID - Type Unspecified