Provider Demographics
NPI:1245223817
Name:BROOMALL RADIOLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:BROOMALL RADIOLOGY ASSOCIATES PC
Other - Org Name:MAIN LINE OPEN MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-663-5910
Mailing Address - Street 1:PO BOX 827275
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-7275
Mailing Address - Country:US
Mailing Address - Phone:215-663-5910
Mailing Address - Fax:215-663-2451
Practice Address - Street 1:590 REED RD
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3654
Practice Address - Country:US
Practice Address - Phone:610-353-7100
Practice Address - Fax:610-353-7101
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOMALL RADIOLOGY ASSOCIATES PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0013923080001Medicaid
PA150197Medicare ID - Type Unspecified