Provider Demographics
NPI:1104843689
Name:CLIFFSIDE PARK IMAGING AND DIAGNOSTIC CENTER, LLC
Entity Type:Organization
Organization Name:CLIFFSIDE PARK IMAGING AND DIAGNOSTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-724-8124
Mailing Address - Street 1:596 ANDERSON AVENUE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010
Mailing Address - Country:US
Mailing Address - Phone:201-945-6747
Mailing Address - Fax:
Practice Address - Street 1:596 ANDERSON AVENUE
Practice Address - Street 2:SUITE 120
Practice Address - City:CLIFFSIDE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07010
Practice Address - Country:US
Practice Address - Phone:201-945-6747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ067492Medicare ID - Type UnspecifiedGROUP #