Provider Demographics
NPI:1104978105
Name:PENNSVILLE RADIOLOGY INC.
Entity type:Organization
Organization Name:PENNSVILLE RADIOLOGY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER RADIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VALENTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-678-8118
Mailing Address - Street 1:248 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PENNSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08070-2724
Mailing Address - Country:US
Mailing Address - Phone:856-678-8118
Mailing Address - Fax:856-678-8130
Practice Address - Street 1:248 S BROADWAY
Practice Address - Street 2:
Practice Address - City:PENNSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08070-2724
Practice Address - Country:US
Practice Address - Phone:856-678-8118
Practice Address - Fax:856-678-8130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3184501Medicaid
NJ3184501Medicaid