Provider Demographics
NPI:1811903578
Name:SHORE ROAD RADIOLOGY ASSOCIATES, PC
Entity type:Organization
Organization Name:SHORE ROAD RADIOLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP MANAGED CARE & REVENUE COMPLIANC
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DELLACERRA
Authorized Official - Suffix:
Authorized Official - Credentials:VP
Authorized Official - Phone:718-630-7103
Mailing Address - Street 1:5800 3RD AVE
Mailing Address - Street 2:LUTHERAN MEDICAL CENTER-MANAGED CARE DEPARTMENT
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3702
Mailing Address - Country:US
Mailing Address - Phone:718-630-7477
Mailing Address - Fax:718-630-7437
Practice Address - Street 1:150 55TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2559
Practice Address - Country:US
Practice Address - Phone:718-630-7477
Practice Address - Fax:718-630-7437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168202085U0001X, 2085R0204X, 2085N0904X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00809412Medicaid
NY00809412Medicaid