Basic Information
| Provider Information | |||||||||
| NPI: | 1982762142 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HACKETTSTOWN RADIOLOGY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 655 | ||||||||
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| City: | HACKETTSTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088501319 | ||||||||
| FaxNumber: | 9088509174 | ||||||||
| Practice Location | |||||||||
| Address1: | 651 WILLOW GROVE ST | ||||||||
| Address2: | HACKETTSTOWN REGIONAL MEDICAL CENTER | ||||||||
| City: | HACKETTSTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088525100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 07/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | LO | ||||||||
| AuthorizedOfficialFirstName: | PAK KAN | ||||||||
| AuthorizedOfficialMiddleName: | ALBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9088506842 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 3041701 | 05 | NJ | MEDICAID |