Provider Demographics
NPI:1790975498
Name:CRESCENT RADIOLOGY PLLC
Entity Type:Organization
Organization Name:CRESCENT RADIOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEMARCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-507-4700
Mailing Address - Street 1:2747 CRESCENT ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-3142
Mailing Address - Country:US
Mailing Address - Phone:718-507-4700
Mailing Address - Fax:
Practice Address - Street 1:2747 CRESCENT ST
Practice Address - Street 2:SUITE 107
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-3142
Practice Address - Country:US
Practice Address - Phone:718-507-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-29
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02917944Medicaid
NY02917944Medicaid