Healthcare Provider Details

I. General information

NPI: 1669837555
Provider Name (Legal Business Name): EDGEWATER IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2015
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 HILLIARD AVE
EDGEWATER NJ
07020-1257
US

IV. Provider business mailing address

23 JULIA PL
BUDD LAKE NJ
07828-2461
US

V. Phone/Fax

Practice location:
  • Phone: 803-673-6355
  • Fax: 866-201-1187
Mailing address:
  • Phone: 803-673-6355
  • Fax: 866-201-1187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. PREETHAM PILLARISETTY
Title or Position: CEO
Credential:
Phone: 803-673-6355