Provider Demographics
NPI:1871549899
Name:PUEBLO RADIOLOGY MEDICAL GROUP INC
Entity type:Organization
Organization Name:PUEBLO RADIOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-682-7984
Mailing Address - Street 1:DEPT LA 21613
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1613
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:949-263-1639
Practice Address - Street 1:250 W PUEBLO ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-3805
Practice Address - Country:US
Practice Address - Phone:805-682-7744
Practice Address - Fax:805-682-3321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0011030Medicaid
CAGR0011034Medicaid
CAGR0011038Medicaid
CAGR001103AMedicaid
CAGR001103BMedicaid
CAZZZ73471ZMedicaid
CAGR001103CMedicaid
CAGR0011035Medicaid
CAGR0011039Medicaid
CAGR0011037Medicaid
CAZZZ50521YOtherBS
CAGR0011037Medicaid
CAGR0011038Medicaid
CAGR0011039Medicaid
CAGR0011030Medicaid
CAZZZ50521YOtherBS
CAGR001103CMedicaid
CACD6004Medicare PIN
CAHW233AMedicare PIN
CAW233BMedicare PIN