Provider Demographics
NPI:1033181458
Name:ADVANCED RADIOLOGY OF HADDONFIELD PA
Entity Type:Organization
Organization Name:ADVANCED RADIOLOGY OF HADDONFIELD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FAZLOLLAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLESTANEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-216-0294
Mailing Address - Street 1:PO BOX 2300
Mailing Address - Street 2:
Mailing Address - City:SO VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08362-2300
Mailing Address - Country:US
Mailing Address - Phone:856-691-9630
Mailing Address - Fax:856-691-2684
Practice Address - Street 1:66 TANNER ST
Practice Address - Street 2:
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033
Practice Address - Country:US
Practice Address - Phone:856-216-0294
Practice Address - Fax:856-216-0299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ087530Medicare PIN
NJ415160Medicare PIN