Provider Demographics
NPI:1528153665
Name:WESTERN IMAGING, MARINA DEL REY
Entity type:Organization
Organization Name:WESTERN IMAGING, MARINA DEL REY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOTYSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:3108-396-4700
Mailing Address - Street 1:9808 VENICE BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232
Mailing Address - Country:US
Mailing Address - Phone:310-836-4700
Mailing Address - Fax:310-836-6925
Practice Address - Street 1:4640 ADMIRALTY WAY
Practice Address - Street 2:SUITE 102
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6621
Practice Address - Country:US
Practice Address - Phone:310-836-4700
Practice Address - Fax:310-836-6925
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN DIAGNOSTIC & THERAPEUTIC RADIOLOGY MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-04
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0017072Medicaid
CAW13956Medicare PIN