Provider Demographics
NPI:1245235407
Name:LACEY DIAGNOSTIC IMAGING, LLC.
Entity Type:Organization
Organization Name:LACEY DIAGNOSTIC IMAGING, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER/ACTIVE, ATTENDING
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-242-2334
Mailing Address - Street 1:833 LACEY RD
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-1200
Mailing Address - Country:US
Mailing Address - Phone:609-242-2334
Mailing Address - Fax:609-242-2402
Practice Address - Street 1:833 LACEY ROAD
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-1200
Practice Address - Country:US
Practice Address - Phone:609-242-2334
Practice Address - Fax:609-242-2402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA053922002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ085215Medicare ID - Type UnspecifiedGROUP NJ MEDICARE NUMBER