Provider Demographics
NPI:1477551653
Name:SOUTH JERSEY RADIOLOGY ASSOCIATES PA
Entity Type:Organization
Organization Name:SOUTH JERSEY RADIOLOGY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:TRAVIS
Authorized Official - Last Name:LUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-362-5391
Mailing Address - Street 1:PO BOX 1710
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-7710
Mailing Address - Country:US
Mailing Address - Phone:856-770-0504
Mailing Address - Fax:856-770-0395
Practice Address - Street 1:100 CARNIE BLVD
Practice Address - Street 2:SUITE B-5
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4512
Practice Address - Country:US
Practice Address - Phone:856-751-0123
Practice Address - Fax:856-751-0535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4299662085B0100X
2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00099913000OtherAMERIHEALTH - HMO
429966OtherHIGHMARK PA BLUE SHIELD
46043OtherCAQH
429966OtherPREMIER BLUE
0016366OtherAETNA
NJ2612704Medicaid
CA3660OtherRAILROAD MEDICARE
1100179OtherHORIZON NJ HEALTH
429966OtherAMERIHEALTH -- PPO
429966OtherHIGHMARK PA BLUE SHIELD