Provider Demographics
NPI:1558497354
Name:MOBILE DIAGNOSTIC TST SERV INC
Entity Type:Organization
Organization Name:MOBILE DIAGNOSTIC TST SERV INC
Other - Org Name:HEALTHTRAC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCDONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-686-7110
Mailing Address - Street 1:4950 GENESEE ST
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14225-5550
Mailing Address - Country:US
Mailing Address - Phone:716-686-7100
Mailing Address - Fax:716-614-3282
Practice Address - Street 1:269 SHEFFIELD ST
Practice Address - Street 2:SUITE 5C
Practice Address - City:MOUNTAINSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07092-2318
Practice Address - Country:US
Practice Address - Phone:908-518-0150
Practice Address - Fax:718-886-5762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ330493Medicare PIN
NJ630000708Medicare ID - Type UnspecifiedRAILROAD
NJHE330493Medicare ID - Type UnspecifiedXRAY