Healthcare Provider Details

I. General information

NPI: 1558497354
Provider Name (Legal Business Name): MOBILE DIAGNOSTIC TST SERV INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 SHEFFIELD ST SUITE 5C
MOUNTAINSIDE NJ
07092-2318
US

IV. Provider business mailing address

4950 GENESEE ST SUITE 180
BUFFALO NY
14225-5550
US

V. Phone/Fax

Practice location:
  • Phone: 908-518-0150
  • Fax: 718-886-5762
Mailing address:
  • Phone: 716-686-7100
  • Fax: 716-614-3282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number State

VIII. Authorized Official

Name: DANIEL T MCDONNELL
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 716-686-7110