1578628772 NPI number — SHORE IMAGING ASSOCIATES MARLTON LLC

Table of content: (NPI 1578628772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578628772 NPI number — SHORE IMAGING ASSOCIATES MARLTON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHORE IMAGING ASSOCIATES MARLTON LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STAT IMAGING AT MARLTON
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578628772
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
324 44TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEA ISLE CITY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08243-1846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-263-4566
Provider Business Mailing Address Fax Number:
856-985-9061

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 BRICK RD
Provider Second Line Business Practice Location Address:
SUITE #101
Provider Business Practice Location Address City Name:
MARLTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08053-2146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-983-5599
Provider Business Practice Location Address Fax Number:
856-985-9061
Provider Enumeration Date:
12/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FOX
Authorized Official First Name:
LYNNE
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
856-983-5599

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X , with the licence number:  22803 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)