=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871665141
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHATHAM MEDICAL RESOURCES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 188 ROUTE 10 W
-----------------------------------------------------
City | EAST HANOVER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-884-8881
-----------------------------------------------------
Fax | 973-884-8893
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 12417
-----------------------------------------------------
City | HAUPPAUGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11788-0513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-884-8881
-----------------------------------------------------
Fax | 973-884-8893
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, MANAGED CARE & CREDENTIALING
-----------------------------------------------------
Name | JACQUELINE MAYER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 631-952-5717
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1200X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
-----------------------------------------------------
License Number | 22406
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------