1053332163 NPI number — BRONX PARK RADIOLOGY ASST PC

Table of content: (NPI 1053332163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053332163 NPI number — BRONX PARK RADIOLOGY ASST PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRONX PARK RADIOLOGY ASST PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053332163
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 631
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT WASHINGTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11050-0631
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-767-1755
Provider Business Mailing Address Fax Number:
516-767-1951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2016 BRONXDALE AVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10462-3388
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-960-9033
Provider Business Practice Location Address Fax Number:
718-823-5131
Provider Enumeration Date:
07/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GADE
Authorized Official First Name:
MARIE
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
718-960-6486

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00668740 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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