Provider Demographics
NPI:1417902446
Name:MEDICAL PARK IMAGING, PA
Entity Type:Organization
Organization Name:MEDICAL PARK IMAGING, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-696-5770
Mailing Address - Street 1:10335 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5763
Mailing Address - Country:US
Mailing Address - Phone:262-240-9870
Mailing Address - Fax:262-240-9869
Practice Address - Street 1:330 RATZER RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-7702
Practice Address - Country:US
Practice Address - Phone:973-696-5770
Practice Address - Fax:973-633-1204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ446376Medicare PIN