Provider Demographics
NPI:1316997893
Name:SOVEREIGN HEALTH IMAGING, LLC
Entity type:Organization
Organization Name:SOVEREIGN HEALTH IMAGING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:HAJJAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-791-4544
Mailing Address - Street 1:630 BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:CARLSTADT
Mailing Address - State:NJ
Mailing Address - Zip Code:07072-0468
Mailing Address - Country:US
Mailing Address - Phone:201-372-1020
Mailing Address - Fax:201-372-1028
Practice Address - Street 1:630 BROAD STREET
Practice Address - Street 2:
Practice Address - City:CARLSTADT
Practice Address - State:NJ
Practice Address - Zip Code:07072-0468
Practice Address - Country:US
Practice Address - Phone:201-372-1020
Practice Address - Fax:201-372-1028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207UN0902X, 207UN0903X, 2085B0100X, 2085N0700X, 2085N0904X, 2085P0229X, 2085R0204X, 2085U0001X, 207U00000X, 207UN0901X, 2085R0202X
2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Multi-Specialty
No207UN0903XAllopathic & Osteopathic PhysiciansNuclear MedicineIn Vivo & In Vitro Nuclear MedicineGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
475214306OtherTAX ID
NJ0133311Medicaid
475214306OtherTAX ID