Provider Demographics
NPI:1063172476
Name:IMAGING CENTER MONTVILLE LLC WAYNE RADIOLOGY CENTER
Entity type:Organization
Organization Name:IMAGING CENTER MONTVILLE LLC WAYNE RADIOLOGY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERSON
Authorized Official - Middle Name:
Authorized Official - Last Name:MAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-720-0050
Mailing Address - Street 1:516 HAMBURG TPKE STE 6
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2063
Mailing Address - Country:US
Mailing Address - Phone:973-720-0050
Mailing Address - Fax:
Practice Address - Street 1:516 HAMBURG TPKE STE 6
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2063
Practice Address - Country:US
Practice Address - Phone:973-720-0050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Single Specialty