Provider Demographics
NPI:1710932603
Name:LARCHMONT IMAGING ASSOCIATES
Entity type:Organization
Organization Name:LARCHMONT IMAGING ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-763-1112
Mailing Address - Street 1:700 E MOREHEAD ST STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 ARK RD
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-3188
Practice Address - Country:US
Practice Address - Phone:609-261-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3226905Medicaid
NJ3226905Medicaid