=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710141353
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INFINITY DIAGNOSTIC GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2008
-----------------------------------------------------
Last Update Date | 08/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 SHREWSBURY PLZ # 376
-----------------------------------------------------
City | SHREWSBURY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07702-4325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-870-6377
-----------------------------------------------------
Fax | 732-571-0196
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 SHREWSBURY PLZ # 376
-----------------------------------------------------
City | SHREWSBURY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07702-4325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-870-6377
-----------------------------------------------------
Fax | 732-571-0196
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | LYDIA WIKOFF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 732-870-6377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335V00000X
-----------------------------------------------------
Taxonomy Name | Portable X-ray and/or Other Portable Diagnostic Imaging Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------