Provider Demographics
NPI:1851445027
Name:TEANECK RADIOLOGY CENTER LLC
Entity type:Organization
Organization Name:TEANECK RADIOLOGY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HELENE
Authorized Official - Middle Name:G
Authorized Official - Last Name:DEFURIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-836-2500
Mailing Address - Street 1:P.O. BOX 609
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816
Mailing Address - Country:US
Mailing Address - Phone:732-390-0040
Mailing Address - Fax:732-390-1856
Practice Address - Street 1:699 TEANECK ROAD
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666
Practice Address - Country:US
Practice Address - Phone:201-836-2500
Practice Address - Fax:201-836-7921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04578500261QR0200X
NJ25MA04933000261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0014087Medicaid
NJ8421710OtherAETNA
NJ4105356OtherGHI
NJ2K4160OtherHEALTHNET
NJANC395OtherOXFORD
NJ8421710OtherAETNA