1912975079 NPI number — MOBILE DIAGNOSTIC SERVICES INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912975079 NPI number — MOBILE DIAGNOSTIC SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOBILE DIAGNOSTIC SERVICES INC
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:
1912975079
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
144 N BEVERWYCK RD
Provider Second Line Business Mailing Address:
PMB 334
Provider Business Mailing Address City Name:
LAKE HIAWATHA
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07034-1909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-812-1300
Provider Business Mailing Address Fax Number:
973-812-0992

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 GALESI DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAYNE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07470-4826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-812-1300
Provider Business Practice Location Address Fax Number:
973-812-0992
Provider Enumeration Date:
03/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDREICH
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
S
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
973-812-1300

Provider Taxonomy Codes

  • Taxonomy code: 335V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3378501 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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