Provider Demographics
NPI:1679502215
Name:968 RIVER ROAD RADIOLOGY
Entity Type:Organization
Organization Name:968 RIVER ROAD RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF RADIOLOGY
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:PORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-616-8100
Mailing Address - Street 1:PO BOX 5075
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-5075
Mailing Address - Country:US
Mailing Address - Phone:856-616-8100
Mailing Address - Fax:856-616-1919
Practice Address - Street 1:968 RIVER ROAD
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:07020
Practice Address - Country:US
Practice Address - Phone:856-616-8100
Practice Address - Fax:856-616-1919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0017507Medicaid
NJ0017507Medicaid