Provider Demographics
NPI:1982694543
Name:SOUTH NASSAU RADIOLOGY PC
Entity Type:Organization
Organization Name:SOUTH NASSAU RADIOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LASTIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-632-4656
Mailing Address - Street 1:PO BOX 5768
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11802-5768
Mailing Address - Country:US
Mailing Address - Phone:516-632-4656
Mailing Address - Fax:
Practice Address - Street 1:1 HEALTHY WAY
Practice Address - Street 2:ATTN: RADIOLOGY
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1551
Practice Address - Country:US
Practice Address - Phone:516-632-4656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01911971Medicaid
NYWX0731Medicare ID - Type Unspecified