1639110240 NPI number — JEANES RADIOLOGY ASSOCIATES, LLC

Table of content: (NPI 1639110240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639110240 NPI number — JEANES RADIOLOGY ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEANES RADIOLOGY ASSOCIATES, 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:
AKUMIN
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:
1639110240
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1619 GRANT AVENUE
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:
19115-3167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-676-3300
Provider Business Mailing Address Fax Number:
215-677-0980

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1619 GRANT AVE
Provider Second Line Business Practice Location Address:
GRANT PLAZA II
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19115-3167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-676-3300
Provider Business Practice Location Address Fax Number:
215-677-0980
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KASSA
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF OPERATIONS
Authorized Official Telephone Number:
904-515-0362

Provider Taxonomy Codes

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

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

  • Identifier: 001221614 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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