MEDICARE: MARINA IDTF OF NJ INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0208X	Mobile Radiology Clinic/Center

General Provider Information

NPI Number	:	1225380066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARINA IDTF OF NJ INC.

Provider Business Mailing Address
First Line	:	251 E 5TH ST
Second Line	:	UNIT 1
City	:	BROOKLYN
State	:	NY
Zip	:	11218-2403
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 ROUTE 17
Second Line	:	SUITE 800
City	:	RUTHERFORD
State	:	NJ
Zip	:	07070-2575
Country	:	US
Telephone Number	:	347-927-6859
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARINA RABINOVICH
Credential	:
Telephone Number	:	347-927-6859

Provider Enumeration Date	:	10/03/2012
Last Update Date	:	10/03/2012

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