Healthcare Provider Details

I. General information

NPI: 1538324777
Provider Name (Legal Business Name): NORTHEASTERN CARDIAC IMAGING ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2008
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 STATE RT 17 N SUITE 310
ROCHELLE PARK NJ
07662-3399
US

IV. Provider business mailing address

218 STATE RT 17 N SUITE 310
ROCHELLE PARK NJ
07662-3399
US

V. Phone/Fax

Practice location:
  • Phone: 201-845-3535
  • Fax:
Mailing address:
  • Phone: 201-845-3535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA69173
License Number StateNJ

VIII. Authorized Official

Name: LEONARDO JOSEPH DIVAGNO
Title or Position: PRESIDENT
Credential: MD
Phone: 201-845-3535