Basic Information
| Provider Information | |||||||||
| NPI: | 1295711661 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMONWEALTH RADIOLOGY ASSOCIATES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 91 STILES RD | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030792846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038939784 | ||||||||
| FaxNumber: | 6038938886 | ||||||||
| Practice Location | |||||||||
| Address1: | 81 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019702714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787411200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 12/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | HOFFMAN | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 8009270002 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 9709011 | 05 | MA | MEDICAID |