Basic Information
| Provider Information | |||||||||
| NPI: | 1346209624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 468 | ||||||||
| Address2: | |||||||||
| City: | BERWICK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 186030468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109560003 | ||||||||
| FaxNumber: | 5707597613 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 LANSDOWNE AVE | ||||||||
| Address2: | |||||||||
| City: | DARBY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102374000 | ||||||||
| FaxNumber: | 6102375641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | D63043 | MD | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD428459 | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 38110065 | 01 | MD | CAREFIRST DC | OTHER | 110800000407536600 | 05 | MD | MEDICAID | KC46SH60340002 | 01 | MD | CAREFIRST | OTHER |