Healthcare Provider Details

I. General information

NPI: 1255607289
Provider Name (Legal Business Name): RADIUM HEALTHCARE PROFESSIONAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2012
Last Update Date: 03/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N BROAD ST SUITE LL3
ELIZABETH NJ
07208-2310
US

IV. Provider business mailing address

700 N BROAD ST SUITE LL3
ELIZABETH NJ
07208-2310
US

V. Phone/Fax

Practice location:
  • Phone: 908-469-1500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number25MA02888800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number25MA08944900
License Number StateNJ

VIII. Authorized Official

Name: RITA U. GORADIA
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 908-469-1500