Provider Demographics
NPI:1841589298
Name:SOVEREIGN MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:SOVEREIGN MEDICAL GROUP LLC
Other - Org Name:NEW JERSEY INSTITUTE OF RADIOLOGY PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:HAJJAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-791-4544
Mailing Address - Street 1:630 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CARLSTADT
Mailing Address - State:NJ
Mailing Address - Zip Code:07072-1169
Mailing Address - Country:US
Mailing Address - Phone:201-372-1020
Mailing Address - Fax:201-372-1028
Practice Address - Street 1:630 BROAD ST
Practice Address - Street 2:
Practice Address - City:CARLSTADT
Practice Address - State:NJ
Practice Address - Zip Code:07072-1169
Practice Address - Country:US
Practice Address - Phone:201-372-1020
Practice Address - Fax:201-372-1028
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOVEREIGN MEDICAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-06
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Single Specialty
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Single Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Single Specialty
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0133311Medicaid
NJ115568Medicare PIN