Provider Demographics
NPI:1710492764
Name:JEFFERSON UNIVERSITY RADIOLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:JEFFERSON UNIVERSITY RADIOLOGY ASSOCIATES, LLC
Other - Org Name:JEFFERSON OUTPATIENT IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CANNON
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-846-7733
Mailing Address - Street 1:800 CRESCENT CENTRE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-7270
Mailing Address - Country:US
Mailing Address - Phone:615-261-2306
Mailing Address - Fax:855-588-3545
Practice Address - Street 1:650 CARNEGIE BOULEVARD
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-1935
Practice Address - Country:US
Practice Address - Phone:615-261-2306
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-12
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PENDINGOtherPENDING