Provider Demographics
NPI:1265409635
Name:LAKES RADIOLOGY PLLC
Entity type:Organization
Organization Name:LAKES RADIOLOGY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IDDO
Authorized Official - Middle Name:
Authorized Official - Last Name:NETANYAHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-857-0094
Mailing Address - Street 1:PO BOX 2004
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4504
Mailing Address - Country:US
Mailing Address - Phone:315-362-5285
Mailing Address - Fax:315-445-2936
Practice Address - Street 1:8395 OSWEGO RD
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-6801
Practice Address - Country:US
Practice Address - Phone:315-857-0094
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKES RADIOLOGY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-03
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
BA0530Medicare PIN