Provider Demographics
NPI:1639110240
Name:JEANES RADIOLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:JEANES RADIOLOGY ASSOCIATES, LLC
Other - Org Name:AKUMIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:KASSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-515-0362
Mailing Address - Street 1:1619 GRANT AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-3167
Mailing Address - Country:US
Mailing Address - Phone:215-676-3300
Mailing Address - Fax:215-677-0980
Practice Address - Street 1:1619 GRANT AVE
Practice Address - Street 2:GRANT PLAZA II
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-3167
Practice Address - Country:US
Practice Address - Phone:215-676-3300
Practice Address - Fax:215-677-0980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001221614Medicaid
PA005188Medicare PIN