Provider Demographics
NPI:1326463449
Name:HEALTH TECH DIAGNOSTIC,LLC
Entity Type:Organization
Organization Name:HEALTH TECH DIAGNOSTIC,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-469-4771
Mailing Address - Street 1:207 SPRINGFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-1534
Mailing Address - Country:US
Mailing Address - Phone:908-469-4771
Mailing Address - Fax:908-327-9634
Practice Address - Street 1:12 KROTIK PL
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-1708
Practice Address - Country:US
Practice Address - Phone:908-469-4771
Practice Address - Fax:908-327-9634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04275000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0887307Medicaid
NJ526391OtherMEDICARE ID
NJ526391OtherMEDICARE ID