Provider Demographics
NPI:1548387863
Name:RADIOLOGY AND MEDICAL MANAGEMENT OF MILLBURN
Entity Type:Organization
Organization Name:RADIOLOGY AND MEDICAL MANAGEMENT OF MILLBURN
Other - Org Name:ADVANCED DIAGNOSTIC IMAGING OF MILLBURN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOYOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-564-5858
Mailing Address - Street 1:25 E WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1416
Mailing Address - Country:US
Mailing Address - Phone:973-564-5858
Mailing Address - Fax:973-564-6386
Practice Address - Street 1:25 E WILLOW ST
Practice Address - Street 2:
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1416
Practice Address - Country:US
Practice Address - Phone:973-564-5858
Practice Address - Fax:973-564-6382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ229042085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2783932OtherAETNA HMO
NJ8618607Medicaid
NJ33783OtherUNIVERSITY HEALTH PLAN
NJ2K0872OtherHEALTHNET
NJ7481363OtherAETNA PPO
NJ2007207OtherFIRST HEALTH
NJ2083813000OtherAMERIHEALTH HMO AND POS
NJ2783932OtherAETNA HMO
NJ624913Medicare PIN