Provider Demographics
NPI:1245392596
Name:ADVANCED RADIOLOGY OF MILLVILLE PA
Entity Type:Organization
Organization Name:ADVANCED RADIOLOGY OF MILLVILLE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FAZLOLLAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLESTANEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-293-1632
Mailing Address - Street 1:PO BOX 2300
Mailing Address - Street 2:
Mailing Address - City:SO VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08362-2300
Mailing Address - Country:US
Mailing Address - Phone:856-293-1632
Mailing Address - Fax:856-293-7810
Practice Address - Street 1:1001 N HIGH STREET
Practice Address - Street 2:
Practice Address - City:MILLVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08332
Practice Address - Country:US
Practice Address - Phone:856-825-0005
Practice Address - Fax:856-825-5576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA031099002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5390702Medicaid
NJ415160Medicare ID - Type Unspecified