Provider Demographics
NPI:1740341049
Name:MAIN MEDICAL IMAGING CENTER
Entity type:Organization
Organization Name:MAIN MEDICAL IMAGING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MANSOUR
Authorized Official - Middle Name:
Authorized Official - Last Name:SAQFELHAIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-777-6661
Mailing Address - Street 1:1003 MAIN AVE # 1011
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-2333
Mailing Address - Country:US
Mailing Address - Phone:973-777-6661
Mailing Address - Fax:973-777-1311
Practice Address - Street 1:1003 MAIN AVE # 1011
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2333
Practice Address - Country:US
Practice Address - Phone:973-777-6661
Practice Address - Fax:973-777-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA0447552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5567505Medicaid
NJ5567505Medicaid
NJ=========OtherTAX ID