Provider Demographics
NPI:1841596897
Name:ULTRASOUND IMAGE CENTER LLC
Entity type:Organization
Organization Name:ULTRASOUND IMAGE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZZAGATTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-427-0324
Mailing Address - Street 1:2351 E ALLEGHENY AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-4431
Mailing Address - Country:US
Mailing Address - Phone:215-427-0324
Mailing Address - Fax:215-427-0308
Practice Address - Street 1:2351 E ALLEGHENY AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19134-4431
Practice Address - Country:US
Practice Address - Phone:215-427-0324
Practice Address - Fax:215-427-0308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA37657261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1025755480001Medicaid