Provider Demographics
NPI:1760733109
Name:PENNSAUKEN DIAGNOSTIC CENTER
Entity Type:Organization
Organization Name:PENNSAUKEN DIAGNOSTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CHIEF EXECUTIVE OFFIC
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAZEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-662-7581
Mailing Address - Street 1:6027 SOUTH CRESCENT BLVD
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08110-6401
Mailing Address - Country:US
Mailing Address - Phone:856-662-7581
Mailing Address - Fax:856-662-7584
Practice Address - Street 1:6027 SOUTH CRESCENT BLVD
Practice Address - Street 2:
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08110-6401
Practice Address - Country:US
Practice Address - Phone:856-662-7581
Practice Address - Fax:856-662-7584
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENNSAUKEN DIAGNOSTIC CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-25
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0311715Medicaid