=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477551653
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH JERSEY RADIOLOGY ASSOCIATES P A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2005
-----------------------------------------------------
Last Update Date | 06/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 CARNIE BLVD SUITE B-5
-----------------------------------------------------
City | VOORHEES
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08043-4512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-751-0123
-----------------------------------------------------
Fax | 856-751-0535
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 FELLOWSHIP RD STE 200
-----------------------------------------------------
City | MOUNT LAUREL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08054-3437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF CREDENTIALING
-----------------------------------------------------
Name | KATE ROELLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 614-689-1691
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085B0100X
-----------------------------------------------------
Taxonomy Name | Body Imaging Physician
-----------------------------------------------------
License Number | 429966
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------