=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205862463
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLANTIC RADIOLOGIST PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2006
-----------------------------------------------------
Last Update Date | 05/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1925 PACIFIC AVE
-----------------------------------------------------
City | ATLANTIC CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08401-6713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-572-8355
-----------------------------------------------------
Fax | 609-572-8356
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 72 W JIMMIE LEEDS RD SUITE 1100
-----------------------------------------------------
City | GALLOWAY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08205-9406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-677-9729
-----------------------------------------------------
Fax | 609-652-7153
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | MR. MICHAEL JENORIKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 609-652-6815
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------