1376591818 NPI number — SILVER LAKE MEDICAL IMAGING, LLC

Table of content: (NPI 1376591818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376591818 NPI number — SILVER LAKE MEDICAL IMAGING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SILVER LAKE MEDICAL IMAGING, LLC
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:
1376591818
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARSAW
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14569-0150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-692-2160
Provider Business Mailing Address Fax Number:
716-692-4342

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARSAW
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14569-1025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-786-1262
Provider Business Practice Location Address Fax Number:
585-786-1251
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OLIVERIO
Authorized Official First Name:
ROSEANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
585-786-1262

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: 02368101 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com