Healthcare Provider Details

I. General information

NPI: 1063172476
Provider Name (Legal Business Name): IMAGING CENTER MONTVILLE LLC WAYNE RADIOLOGY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2021
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 HAMBURG TPKE STE 6
WAYNE NJ
07470-2063
US

IV. Provider business mailing address

516 HAMBURG TPKE STE 6
WAYNE NJ
07470-2063
US

V. Phone/Fax

Practice location:
  • Phone: 973-720-0050
  • Fax:
Mailing address:
  • Phone: 973-720-0050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JEFFERSON MAR
Title or Position: ADMINISTRATOR
Credential:
Phone: 973-720-0050