Basic Information
| Provider Information | |||||||||
| NPI: | 1356390561 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST RADIOLOGY ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 PINE ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | ROCKAWAY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078663139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9736277922 | ||||||||
| FaxNumber: | 9736275957 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 POCONO RD | ||||||||
| Address2: | |||||||||
| City: | DENVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078342954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9736256000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 01/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | WEXLER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9736256650 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 7661207 | 05 | NJ | MEDICAID |