Provider Demographics
NPI:1710996509
Name:MOSHOLU PARK RADIOLOGY PC
Entity Type:Organization
Organization Name:MOSHOLU PARK RADIOLOGY PC
Other - Org Name:MOSHOLU PARK RADIOLOGY PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDRESITO
Authorized Official - Middle Name:B
Authorized Official - Last Name:PACIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-933-6969
Mailing Address - Street 1:MOSHOLU PARK RADIOLOGY PC
Mailing Address - Street 2:3130 GRAND CONCOURSE STE 1P
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458
Mailing Address - Country:US
Mailing Address - Phone:718-933-6969
Mailing Address - Fax:718-933-6970
Practice Address - Street 1:MOSHOLU PARK RADIOLOGY PC
Practice Address - Street 2:3130 GRAND CONCOURSE STE 1P
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458
Practice Address - Country:US
Practice Address - Phone:718-933-6969
Practice Address - Fax:718-933-6970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12521312085B0100X, 2085N0904X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
Not Answered2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
Not Answered2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00234428Medicaid
NY00234428Medicaid
NY328662Medicare ID - Type Unspecified