1760400204 NPI number — DEDHAM MRI INC

Table of content: (NPI 1760400204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760400204 NPI number — DEDHAM MRI INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEDHAM MRI 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:
OPEN MRI OF DEDHAM
Provider Other Organization Name Type Code:
5
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:
1760400204
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1455 BROAD ST
Provider Second Line Business Mailing Address:
4TH FLOOR
Provider Business Mailing Address City Name:
BLOOMFIELD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-873-9889
Provider Business Mailing Address Fax Number:
973-707-1127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 PROVIDENCE HWY ROUTE 1
Provider Second Line Business Practice Location Address:
STE 210
Provider Business Practice Location Address City Name:
DEDHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-329-0600
Provider Business Practice Location Address Fax Number:
781-329-1713
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VALLA
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
973-873-9850

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1528980 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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