Basic Information
| Provider Information | |||||||||
| NPI: | 1366428153 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMAGING SUBSPECIALISTS OF NORTH JERSEY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3607 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477353607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004672392 | ||||||||
| FaxNumber: | 8124716650 | ||||||||
| Practice Location | |||||||||
| Address1: | 703 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PATERSON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 075032621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737542645 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 01/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | YUPPA | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| 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 | 2085R0202X | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 9053107 | 05 | NJ | MEDICAID |