1003872953 NPI number — MRI OF WOODBRIDGE LLC

Table of content: (NPI 1003872953)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003872953 NPI number — MRI OF WOODBRIDGE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MRI OF WOODBRIDGE 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:
Provider Other Organization Name Type Code:
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:
1003872953
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 828393
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19182-8393
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-381-8686
Provider Business Mailing Address Fax Number:
732-499-7724

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 SAINT GEORGES AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AVENEL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07001-1000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-574-0742
Provider Business Practice Location Address Fax Number:
732-574-0143
Provider Enumeration Date:
04/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FONTANA
Authorized Official First Name:
LEO
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
732-574-0742

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X , with the licence number:  22624 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0200X , with the licence number: 22624 , 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)

  • Identifier: 1166754 . This is a "HORIZON NJ HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 134438XX . This is a "PREFERRED CARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0268620000 . This is a "AMERIHEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1K2970 . This is a "HEALTHNET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 347671200 . This is a "US DEPARTMENT OF LABOR" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2308288 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: A2539097 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 188501 . This is a "AMERIGROUP" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 343114 . This is a "KEYSTONE HEALTH PLAN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 4199032 . This is a "GHI" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: CH3126 . This is a "PALMETTO GBA RAILROAD MED" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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