Provider Demographics
NPI:1295940435
Name:NASSAU-SUFFOLK RADIOLOGICAL ASSOCIATES, P.C.
Entity type:Organization
Organization Name:NASSAU-SUFFOLK RADIOLOGICAL ASSOCIATES, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONACCI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-968-4916
Mailing Address - Street 1:2780 MIDDLE COUNTRY ROAD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755
Mailing Address - Country:US
Mailing Address - Phone:631-588-4500
Mailing Address - Fax:631-588-4595
Practice Address - Street 1:20 WEST JOHN STREET
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757
Practice Address - Country:US
Practice Address - Phone:631-226-2230
Practice Address - Fax:631-226-3024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114256174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00387302Medicaid
3156405511Medicare PIN
NYCO8295Medicare UPIN
NYW05511Medicare ID - Type UnspecifiedPROVIDER