Provider Demographics
NPI:1679764583
Name:UNIVERSITY IMAGING CENTER, LLC
Entity Type:Organization
Organization Name:UNIVERSITY IMAGING CENTER, LLC
Other - Org Name:UNIVERSITY IMAGING CENTER OF CHERRY HILL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:
Authorized Official - Last Name:PERNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-692-1198
Mailing Address - Street 1:PO BOX 1210A
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08362-1210
Mailing Address - Country:US
Mailing Address - Phone:856-692-1198
Mailing Address - Fax:
Practice Address - Street 1:13 W ORMOND AVE
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-3041
Practice Address - Country:US
Practice Address - Phone:856-616-9400
Practice Address - Fax:856-616-9107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY IMAGING CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-06
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22413261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0148466Medicaid
NJ124066Medicare PIN