Healthcare Provider Details

I. General information

NPI: 1780989103
Provider Name (Legal Business Name): LIAMOT VASCULAR IMAGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2011
Last Update Date: 05/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 BELMONT CIR
COLUMBUS NJ
08022-9714
US

IV. Provider business mailing address

30 BELMONT CIR
COLUMBUS NJ
08022-9714
US

V. Phone/Fax

Practice location:
  • Phone: 609-298-2910
  • Fax: 609-450-7224
Mailing address:
  • Phone: 609-298-2910
  • Fax: 609-450-7224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25MA08401100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PRATHIBHA POTHARLANKA
Title or Position: OWNER
Credential: M.D.
Phone: 609-298-2910