Provider Demographics
NPI:1639217425
Name:MARINE PARK RADIOLOGY PC
Entity Type:Organization
Organization Name:MARINE PARK RADIOLOGY PC
Other - Org Name:BROOKLYN MEDICAL IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALFREDO
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-375-6000
Mailing Address - Street 1:PO BOX 13245
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-0840
Mailing Address - Country:US
Mailing Address - Phone:631-952-5701
Mailing Address - Fax:631-952-5740
Practice Address - Street 1:450 AVENUE P
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-1902
Practice Address - Country:US
Practice Address - Phone:718-375-6000
Practice Address - Fax:718-375-6576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02358643Medicaid
NYW9L411Medicare PIN