1578569679 NPI number — TRISTATE IMAGING CONSULTANTS, LLC

Table of content: (NPI 1578569679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578569679 NPI number — TRISTATE IMAGING CONSULTANTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRISTATE IMAGING CONSULTANTS, 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:
6
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:
1578569679
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 827275
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:
19182-7275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-663-5910
Provider Business Mailing Address Fax Number:
215-663-2451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1322 ROUTE 72 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANAHAWKIN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08050-2489
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-978-7900
Provider Business Practice Location Address Fax Number:
609-978-7544
Provider Enumeration Date:
06/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CARR
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
215-663-5910

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8488207 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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