Provider Demographics
NPI:1285676726
Name:ENGLEWOOD IMAGING CENTER, PA
Entity type:Organization
Organization Name:ENGLEWOOD IMAGING CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:BALDASSARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-567-6156
Mailing Address - Street 1:220 OXFORD DR
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-3118
Mailing Address - Country:US
Mailing Address - Phone:201-567-6156
Mailing Address - Fax:201-871-8708
Practice Address - Street 1:220 OXFORD DR
Practice Address - Street 2:
Practice Address - City:TENAFLY
Practice Address - State:NJ
Practice Address - Zip Code:07670-3118
Practice Address - Country:US
Practice Address - Phone:201-567-6156
Practice Address - Fax:201-871-8708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2956900Medicaid
NJ2956900Medicaid