Healthcare Provider Details

I. General information

NPI: 1114044708
Provider Name (Legal Business Name): ADVANCED DIAGNOSTIC IMAGING OF NEW JERSEY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 STATE HIGHWAY ROUTE 17 NORTH
PARAMUS NJ
07652
US

IV. Provider business mailing address

34 ROUTE 17 NORTH
PARAMUS NJ
07652
US

V. Phone/Fax

Practice location:
  • Phone: 201-368-2005
  • Fax: 201-368-1431
Mailing address:
  • Phone: 201-368-2005
  • Fax: 201-368-1431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number22548
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier374421
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerPTAN
# 2
Identifier8149909
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: MR. VICTOR M MORA
Title or Position: ADMINISTRATOR,
Credential:
Phone: 201-368-2005