Provider Demographics
NPI:1891703872
Name:NORTH FORK RADIOLOGY PC
Entity Type:Organization
Organization Name:NORTH FORK RADIOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-727-2755
Mailing Address - Street 1:1333 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901
Mailing Address - Country:US
Mailing Address - Phone:631-727-2755
Mailing Address - Fax:631-208-9521
Practice Address - Street 1:1333 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901
Practice Address - Country:US
Practice Address - Phone:631-727-2755
Practice Address - Fax:631-208-9521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00930429Medicaid
NYW11401OtherBC/BS
NYCF3402OtherRR MEDICARE
NYW11401Medicare PIN
NYW11403Medicare PIN