Provider Demographics
NPI:1669837555
Name:EDGEWATER IMAGING LLC
Entity Type:Organization
Organization Name:EDGEWATER IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PREETHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PILLARISETTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-673-6355
Mailing Address - Street 1:23 JULIA PL
Mailing Address - Street 2:
Mailing Address - City:BUDD LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07828-2461
Mailing Address - Country:US
Mailing Address - Phone:803-673-6355
Mailing Address - Fax:866-201-1187
Practice Address - Street 1:18 HILLIARD AVE
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:07020-1257
Practice Address - Country:US
Practice Address - Phone:803-673-6355
Practice Address - Fax:866-201-1187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile