Healthcare Provider Details

I. General information

NPI: 1346240256
Provider Name (Legal Business Name): JENNERSVILLE RADIOLOGY, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 W BALTIMORE PIKE
WEST GROVE PA
19390-9459
US

IV. Provider business mailing address

2 MERIDIAN BLVD 2ND FLOOR
WYOMISSING PA
19610-3202
US

V. Phone/Fax

Practice location:
  • Phone: 610-372-4957
  • Fax:
Mailing address:
  • Phone: 610-372-4957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StatePA

VIII. Authorized Official

Name: TRACY CARMELLINI
Title or Position: HEAD DOCTOR
Credential: M.D.
Phone: 610-372-4957