Provider Demographics
NPI:1124012018
Name:SEAWAY RADIOLOGY PC
Entity Type:Organization
Organization Name:SEAWAY RADIOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR OF GROUP
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:M
Authorized Official - Last Name:GHARAGOZLOO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-393-1215
Mailing Address - Street 1:27 DOCKSIDE DR # 27
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13664-3231
Mailing Address - Country:US
Mailing Address - Phone:315-482-2511
Mailing Address - Fax:315-482-2015
Practice Address - Street 1:4 FULLER ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA BAY
Practice Address - State:NY
Practice Address - Zip Code:13607-1316
Practice Address - Country:US
Practice Address - Phone:315-482-2511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1985562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02728623Medicaid
NY02728623Medicaid