1720085640 NPI number — COMMUNITY RADIOLOGY, P.A.

Table of content: (NPI 1720085640)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720085640 NPI number — COMMUNITY RADIOLOGY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY RADIOLOGY, P.A.
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:
1720085640
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:
2800 ROUTE 130 N
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
CINNAMINSON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08077-3035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-829-4555
Provider Business Mailing Address Fax Number:
856-829-6644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
434 NEW JERSEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABSECON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08201-2423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-383-0500
Provider Business Practice Location Address Fax Number:
609-383-0376
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CHERRY
Authorized Official First Name:
RESA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
856-829-4555

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  22514 , 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: 3430502 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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