Provider Demographics
NPI:1558429019
Name:GARDEN STATE OPEN MRI DIAGNOSTIC CENTER INC
Entity Type:Organization
Organization Name:GARDEN STATE OPEN MRI DIAGNOSTIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ABDUR
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-614-9400
Mailing Address - Street 1:831 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-8400
Mailing Address - Country:US
Mailing Address - Phone:973-614-9400
Mailing Address - Fax:973-614-9441
Practice Address - Street 1:831 MAIN AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-8400
Practice Address - Country:US
Practice Address - Phone:973-614-9400
Practice Address - Fax:973-614-9441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ261QM1200X261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0063398Medicaid