1083615561 NPI number — KONIVER FISS MANSOORY MD PA

Table of content: (NPI 1083615561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083615561 NPI number — KONIVER FISS MANSOORY MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KONIVER FISS MANSOORY MD PA
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:
PAPASTAVROS ASSOCIATES MEDICAL IMAGING LLC
Provider Other Organization Name Type Code:
3
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:
1083615561
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1160 PITTSFORD VICTOR RD STE D
Provider Second Line Business Mailing Address:
SECOND FLOOR
Provider Business Mailing Address City Name:
PITTSFORD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14534-3825
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-218-8012
Provider Business Mailing Address Fax Number:
585-218-8099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 AUGUSTINE CUT OFF
Provider Second Line Business Practice Location Address:
BLDG. 4
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19803-4461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-652-3016
Provider Business Practice Location Address Fax Number:
302-652-2534
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SCOLA
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
302-652-3016

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  1989029182 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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