Healthcare Provider Details

I. General information

NPI: 1164851705
Provider Name (Legal Business Name): FIRST CHOICE DIAGNOSTICS RADIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2013
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 W END AVE SUITE 14
SOMERVILLE NJ
08876
US

IV. Provider business mailing address

150 W END AVE SUITE 14
SOMERVILLE NJ
08876-1834
US

V. Phone/Fax

Practice location:
  • Phone: 908-448-9108
  • Fax: 908-279-1039
Mailing address:
  • Phone: 908-448-9108
  • Fax: 908-279-1039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA06075200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JESSIE KANE
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 215-932-2762