Healthcare Provider Details

I. General information

NPI: 1568705101
Provider Name (Legal Business Name): PROTOCOL IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2013
Last Update Date: 04/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 BIRCH ST
BLOOMFIELD NJ
07003-4004
US

IV. Provider business mailing address

26 BIRCH ST
BLOOMFIELD NJ
07003-4004
US

V. Phone/Fax

Practice location:
  • Phone: 973-768-1304
  • Fax:
Mailing address:
  • Phone: 973-768-1304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. DOMINICK CARUSO
Title or Position: VASCULAR TECHNOLOGIST
Credential:
Phone: 973-768-1304