Provider Demographics
NPI:1356318760
Name:ADVANCED MAGNETIC IMAGING
Entity Type:Organization
Organization Name:ADVANCED MAGNETIC IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:FESTANTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-619-6294
Mailing Address - Street 1:6416 BERGENLINE AVENUE
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093
Mailing Address - Country:US
Mailing Address - Phone:201-295-1099
Mailing Address - Fax:201-295-1035
Practice Address - Street 1:6416 BERGENLINE AVENUE
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093
Practice Address - Country:US
Practice Address - Phone:201-295-1099
Practice Address - Fax:201-295-1035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-03
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ227882085R0202X, 261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7425805Medicaid
NJ7425805Medicaid