Provider Demographics
NPI:1083782460
Name:SOUTH SHORE NEUROLOGIC ASSOCIATES PC
Entity Type:Organization
Organization Name:SOUTH SHORE NEUROLOGIC ASSOCIATES PC
Other - Org Name:BROOKHAVEN MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:GERALD
Authorized Official - Last Name:MORETA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-758-1910
Mailing Address - Street 1:77 MEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772
Mailing Address - Country:US
Mailing Address - Phone:631-758-1910
Mailing Address - Fax:631-475-7185
Practice Address - Street 1:77 MEDFORD AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1281
Practice Address - Country:US
Practice Address - Phone:631-654-5555
Practice Address - Fax:631-475-7185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01259347Medicaid
NYW19651Medicare PIN