Provider Demographics
NPI:1225104979
Name:BETHPAGE MAGNETIC RESONANCE IMAGING, PC
Entity Type:Organization
Organization Name:BETHPAGE MAGNETIC RESONANCE IMAGING, PC
Other - Org Name:BETHPAGE OPEN MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP, MANAGED CARE & CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-579-8500
Mailing Address - Street 1:PO BOX 11295
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-0973
Mailing Address - Country:US
Mailing Address - Phone:516-579-8500
Mailing Address - Fax:516-579-5974
Practice Address - Street 1:4277 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-5709
Practice Address - Country:US
Practice Address - Phone:516-579-8500
Practice Address - Fax:516-579-5974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0235841Medicaid
NY0235841Medicaid