Healthcare Provider Details

I. General information

NPI: 1932571593
Provider Name (Legal Business Name): SOVEREIGN HEALTH IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 10/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 BROAD ST LOWER LEVEL
CARLSTADT NJ
07072-1169
US

IV. Provider business mailing address

85 HARRISTOWN RD 2ND FLOOR
GLEN ROCK NJ
07452-3329
US

V. Phone/Fax

Practice location:
  • Phone: 201-372-1020
  • Fax: 201-372-1028
Mailing address:
  • Phone: 201-703-5500
  • Fax: 201-703-5564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN H. HAJJAR
Title or Position: OWNER
Credential: MD
Phone: 201-372-1020