Basic Information
| Provider Information | |||||||||
| NPI: | 1629064548 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL PENNSYLVANIA MRI CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 629D LOWTHER RD | ||||||||
| Address2: | |||||||||
| City: | LEWISBERRY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173399527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179382765 | ||||||||
| FaxNumber: | 7179323095 | ||||||||
| Practice Location | |||||||||
| Address1: | 4665 E TRINDLE RD | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170503640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179750445 | ||||||||
| FaxNumber: | 7177319165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 01/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | JAGANNATH | ||||||||
| AuthorizedOfficialFirstName: | ANAND | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7179750445 | ||||||||
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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 | NONE | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 001800134 | 05 | PA | MEDICAID |