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General NPI Number Information
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NPI Number | 1134354210
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Entity Type | Organization
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Legal Business Name | PROGRESSIVE DIAGNOSTIC IMAGING, LLC
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Dates
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Enumeration Date | 05/19/2009
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Last Update Date | 05/19/2009
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Provider Practice Location Address
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Address Line | 44 ROUTE 23 NORTH SUITE 16
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City | RIVERDALE
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State | NJ
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Zip | 07457
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Country | US
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Telephone | 973-839-5004
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Fax | 973-839-5006
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Provider Business Mailing Address
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Address Line | 44 ROUTE 23 NORTH SUITE 16
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City | RIVERDALE
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State | NJ
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Zip | 07457
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Country | US
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Telephone | 973-839-5004
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Fax | 973-839-5006
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Authorized Official
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Title or Position | PRINCIPAL/PRACTICE ADMINISTRATOR
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Name | MR. MARCUS SPATIDOL
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Credential |
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Telephone | 973-839-5004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 24086
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 24086
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License Number State | NJ
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