Provider Demographics
NPI:1295040269
Name:KM RADIOLOGY, LLC
Entity Type:Organization
Organization Name:KM RADIOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KETANG
Authorized Official - Middle Name:H
Authorized Official - Last Name:MODI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-595-7112
Mailing Address - Street 1:23 MOUNTAINVIEW CT
Mailing Address - Street 2:
Mailing Address - City:TOTOWA
Mailing Address - State:NJ
Mailing Address - Zip Code:07512-1654
Mailing Address - Country:US
Mailing Address - Phone:973-595-7112
Mailing Address - Fax:
Practice Address - Street 1:23 MOUNTAINVIEW CT
Practice Address - Street 2:
Practice Address - City:TOTOWA
Practice Address - State:NJ
Practice Address - Zip Code:07512-1654
Practice Address - Country:US
Practice Address - Phone:973-595-7112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07370200261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
059431BSQOtherMEDICARE ID#
NJ1396736468OtherINDIVIDUAL NPI
NJ8900507Medicaid
059431BSQOtherMEDICARE ID#