Provider Demographics
NPI:1194810531
Name:MONTCLAIR RADIOLOGICAL ASSOC ,PA
Entity type:Organization
Organization Name:MONTCLAIR RADIOLOGICAL ASSOC ,PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LASZCZYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-284-0038
Mailing Address - Street 1:116 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2930
Mailing Address - Country:US
Mailing Address - Phone:973-284-0028
Mailing Address - Fax:973-778-6203
Practice Address - Street 1:20 HIGH ST
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110
Practice Address - Country:US
Practice Address - Phone:973-284-0020
Practice Address - Fax:973-284-6310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ233992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2608103Medicaid
NJ2608103Medicaid