Provider Demographics
NPI:1003872953
Name:MRI OF WOODBRIDGE LLC
Entity Type:Organization
Organization Name:MRI OF WOODBRIDGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:FONTANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-574-0742
Mailing Address - Street 1:PO BOX 828393
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-8393
Mailing Address - Country:US
Mailing Address - Phone:732-381-8686
Mailing Address - Fax:732-499-7724
Practice Address - Street 1:1500 SAINT GEORGES AVE
Practice Address - Street 2:
Practice Address - City:AVENEL
Practice Address - State:NJ
Practice Address - Zip Code:07001-1000
Practice Address - Country:US
Practice Address - Phone:732-574-0742
Practice Address - Fax:732-574-0143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22624261QM1200X, 261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1166754OtherHORIZON NJ HEALTH
NJ134438XXOtherPREFERRED CARE
NJ0268620000OtherAMERIHEALTH
NJ1K2970OtherHEALTHNET
NJ347671200OtherUS DEPARTMENT OF LABOR
NJ2308288OtherAETNA
NJA2539097OtherOXFORD
NJ188501OtherAMERIGROUP
NJ343114OtherKEYSTONE HEALTH PLAN
NJ4199032OtherGHI
NJCH3126OtherPALMETTO GBA RAILROAD MED
NJA2539097OtherOXFORD
NJ188501OtherAMERIGROUP