Basic Information
| Provider Information | |||||||||
| NPI: | 1548501026 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | QUANTUM IMAGING & THERAPEUTIC ASSOCIATES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 629D LOWTHER RD | ||||||||
| Address2: | |||||||||
| City: | LEWISBERRY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173399527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179325200 | ||||||||
| FaxNumber: | 7179323095 | ||||||||
| Practice Location | |||||||||
| Address1: | 629D LOWTHER RD | ||||||||
| Address2: | |||||||||
| City: | LEWISBERRY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173399527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179325200 | ||||||||
| FaxNumber: | 7179323095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2013 | ||||||||
| LastUpdateDate: | 03/08/2013 | ||||||||
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| AuthorizedOfficialLastName: | BERGEY | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/ CEO | ||||||||
| AuthorizedOfficialTelephone: | 7179325200 | ||||||||
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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 | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0016172390085 | 05 | PA | MEDICAID |