Healthcare Provider Details

I. General information

NPI: 1912144411
Provider Name (Legal Business Name): MEDICAL DIVERSIFIED SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2009
Last Update Date: 01/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 HIGHWAY 36 E
NORTH MIDDLETOWN NJ
07748-5258
US

IV. Provider business mailing address

PO BOX 442
PORT MONMOUTH NJ
07758-0442
US

V. Phone/Fax

Practice location:
  • Phone: 732-787-4068
  • Fax: 732-787-6032
Mailing address:
  • Phone: 732-787-4068
  • Fax: 732-787-0632

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: MRS. KELLY- ANN MURRAY
Title or Position: MANAGER
Credential:
Phone: 732-787-0468