Provider Demographics
NPI:1093859142
Name:NEW JERSEY ADVANCED DIAGNOSTIC IMAGING
Entity Type:Organization
Organization Name:NEW JERSEY ADVANCED DIAGNOSTIC IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:KRONFELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-338-3416
Mailing Address - Street 1:1145 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2951
Mailing Address - Country:US
Mailing Address - Phone:973-338-3416
Mailing Address - Fax:973-338-3415
Practice Address - Street 1:495 N 13TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1317
Practice Address - Country:US
Practice Address - Phone:973-338-3416
Practice Address - Fax:973-338-3415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0019143Medicaid
74674Medicare ID - Type Unspecified