Healthcare Provider Details

I. General information

NPI: 1023498805
Provider Name (Legal Business Name): NORTHEAST RADIOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 SAND PIT RD STE 101
DANBURY CT
06810-4032
US

IV. Provider business mailing address

3839 DANBURY RD
BREWSTER NY
10509-5412
US

V. Phone/Fax

Practice location:
  • Phone: 203-797-1770
  • Fax: 203-207-3242
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: TONI COOPER
Title or Position: DIRECTOR OF CREDENTIALING
Credential:
Phone: 754-206-6198