Provider Demographics
NPI:1114044708
Name:ADVANCED DIAGNOSTIC IMAGING OF NEW JERSEY INC
Entity Type:Organization
Organization Name:ADVANCED DIAGNOSTIC IMAGING OF NEW JERSEY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR,
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:M
Authorized Official - Last Name:MORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-368-2005
Mailing Address - Street 1:34 ROUTE 17 NORTH
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652
Mailing Address - Country:US
Mailing Address - Phone:201-368-2005
Mailing Address - Fax:201-368-1431
Practice Address - Street 1:34 STATE HIGHWAY ROUTE 17 NORTH
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652
Practice Address - Country:US
Practice Address - Phone:201-368-2005
Practice Address - Fax:201-368-1431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22548261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ374421OtherPTAN
NJ8149909Medicaid