Provider Demographics
NPI:1497700702
Name:GARDEN STATE MRI CORP
Entity Type:Organization
Organization Name:GARDEN STATE MRI CORP
Other - Org Name:EASTLANTIC DIAGNOSTIC INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAUITO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-794-2337
Mailing Address - Street 1:PO BOX 1444
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08362-1444
Mailing Address - Country:US
Mailing Address - Phone:856-794-2337
Mailing Address - Fax:856-205-9925
Practice Address - Street 1:1470 S MAIN RD
Practice Address - Street 2:BUILDING 2
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6588
Practice Address - Country:US
Practice Address - Phone:856-690-0300
Practice Address - Fax:856-205-9925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA051448002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0-1000769500OtherAMERICHOICE
40184OtherAMERIGROUP
1333467OtherAETNA
1025244OtherHORIZON NJ HEALTH
1276753OtherUNITED HEALTHCARE
NJ1528301Medicaid
0-401564000OtherAMERIHEALTH
0-49332OtherCIGNA
NJ101191OtherMEDICAR E GROUP NUMBER
ANC929OtherOXFORD
0-401564000OtherAMERIHEALTH