Provider Demographics
NPI:1760447692
Name:PARK AVENUE ASSOCIATES IN RADIOLOGY PC
Entity Type:Organization
Organization Name:PARK AVENUE ASSOCIATES IN RADIOLOGY PC
Other - Org Name:SOUTHERN TIER IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-729-2125
Mailing Address - Street 1:PO BOX 23
Mailing Address - Street 2:
Mailing Address - City:CANAJOHARIE
Mailing Address - State:NY
Mailing Address - Zip Code:13317-0023
Mailing Address - Country:US
Mailing Address - Phone:315-362-5285
Mailing Address - Fax:
Practice Address - Street 1:32-36 HARRISON ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2122
Practice Address - Country:US
Practice Address - Phone:607-763-6104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00553397Medicaid
NY52019AMedicare PIN