Provider Demographics
NPI:1760659585
Name:SPECIALTY PORTABLE X-RAY INC
Entity Type:Organization
Organization Name:SPECIALTY PORTABLE X-RAY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-432-3800
Mailing Address - Street 1:99 JERICHO TPKE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-1015
Mailing Address - Country:US
Mailing Address - Phone:516-432-3800
Mailing Address - Fax:516-897-3915
Practice Address - Street 1:99 JERICHO TPKE
Practice Address - Street 2:SUITE 204
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-1015
Practice Address - Country:US
Practice Address - Phone:516-432-3800
Practice Address - Fax:516-897-3915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29021253335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY97Z311OtherBCBS
NY02849241Medicaid
NY97Z311OtherBCBS
NY02849241Medicaid
NY97Z311Medicare PIN