Provider Demographics
NPI:1205862463
Name:ATLANTIC RADIOLOGIST PA
Entity Type:Organization
Organization Name:ATLANTIC RADIOLOGIST PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JENORIKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-652-6815
Mailing Address - Street 1:72 W JIMMIE LEEDS RD
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-9406
Mailing Address - Country:US
Mailing Address - Phone:609-677-9729
Mailing Address - Fax:609-652-7153
Practice Address - Street 1:1925 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-6713
Practice Address - Country:US
Practice Address - Phone:609-572-8355
Practice Address - Fax:609-572-8356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2603705Medicaid
143125Medicare ID - Type Unspecified