Provider Demographics
NPI:1699729848
Name:VANOWEN RADIOLOGICAL MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:VANOWEN RADIOLOGICAL MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSSIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-902-2951
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93062-0190
Mailing Address - Country:US
Mailing Address - Phone:805-522-5940
Mailing Address - Fax:805-522-6401
Practice Address - Street 1:15107 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4542
Practice Address - Country:US
Practice Address - Phone:818-902-2951
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ73155ZOtherBLUE SHIELD
CU0807OtherRAILROAD MEDICARE
CAZZZ73155ZMedicaid
CU0807OtherRAILROAD MEDICARE
W10705CMedicare ID - Type Unspecified
ZZZ73155ZOtherBLUE SHIELD