Provider Demographics
NPI:1881765659
Name:NEW JERSEY DIAGNOSTIC IMAGING & THERAPY, PA
Entity type:Organization
Organization Name:NEW JERSEY DIAGNOSTIC IMAGING & THERAPY, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP, MANAGED CARE & CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-952-5717
Mailing Address - Street 1:PO BOX 14068
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-0789
Mailing Address - Country:US
Mailing Address - Phone:732-840-8300
Mailing Address - Fax:732-840-6453
Practice Address - Street 1:198 JACK MARTIN BLVD
Practice Address - Street 2:A-3
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-7769
Practice Address - Country:US
Practice Address - Phone:732-840-8300
Practice Address - Fax:732-840-6453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22234261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3387704Medicaid
NJ3387704Medicaid