1629108063 NPI number — SOUTHTOWNS RADIOLOGY ASSOCIATES, LLC

Table of content: (NPI 1629108063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629108063 NPI number — SOUTHTOWNS RADIOLOGY ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHTOWNS RADIOLOGY ASSOCIATES, 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:
1629108063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3040 AMSDELL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMBURG
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14075-5835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-649-9000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3040 AMSDELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMBURG
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14075-5835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-649-9000
Provider Business Practice Location Address Fax Number:
716-649-9005
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOYCE
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
716-649-9000

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: CE8352 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00026681804 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 040426000332 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 03069821 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000508387008 . This is a "BCBS WESTERN NY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 146156FF . This is a "PREFERRED CARE" identifier . This identifiers is of the category "OTHER".




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