Provider Demographics
NPI:1023498805
Name:NORTHEAST RADIOLOGY PC
Entity type:Organization
Organization Name:NORTHEAST RADIOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:754-206-6198
Mailing Address - Street 1:3839 DANBURY RD
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-5412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67 SAND PIT RD STE 101
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4032
Practice Address - Country:US
Practice Address - Phone:203-797-1770
Practice Address - Fax:203-207-3242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-05
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCO2142Medicare UPIN