Provider Demographics
NPI:1336132992
Name:IMAGING PROFESSIONALS OF PENNSYLVANIA PC
Entity Type:Organization
Organization Name:IMAGING PROFESSIONALS OF PENNSYLVANIA PC
Other - Org Name:ACADEMY IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-707-1100
Mailing Address - Street 1:1455 BROAD ST
Mailing Address - Street 2:4TH FLOOR IMAGING PROFESSIONALS OF PENNSYLVANIA PC
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3003
Mailing Address - Country:US
Mailing Address - Phone:973-707-1100
Mailing Address - Fax:973-707-1127
Practice Address - Street 1:9140 ACADEMY RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-2853
Practice Address - Country:US
Practice Address - Phone:888-440-6494
Practice Address - Fax:330-759-1501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
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
PA0011008510024Medicaid
PA067517Medicare ID - Type Unspecified