Healthcare Provider Details

I. General information

NPI: 1073787826
Provider Name (Legal Business Name): BERGENLINE X RAY DIAGNOSTIC CENTER CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 08/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 43RD ST
UNION CITY NJ
07087-5010
US

IV. Provider business mailing address

402 43RD ST
UNION CITY NJ
07087-5010
US

V. Phone/Fax

Practice location:
  • Phone: 201-348-6060
  • Fax: 201-348-2064
Mailing address:
  • Phone: 201-348-6060
  • Fax: 201-348-2064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number23058
License Number StateNJ

VIII. Authorized Official

Name: MR. PEDRO RODRIGUEZ
Title or Position: PRESIDENT/CEO
Credential:
Phone: 201-348-6060