Healthcare Provider Details

I. General information

NPI: 1144946534
Provider Name (Legal Business Name): NORTHWELL DIAGNOSTIC GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 01/30/2023
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 NORTHPOINT PKWY STE P4
WEST PALM BEACH FL
33407-1973
US

IV. Provider business mailing address

801 NORTHPOINT PKWY STE 313
WEST PALM BEACH FL
33407-1973
US

V. Phone/Fax

Practice location:
  • Phone: 212-288-2823
  • Fax: 212-208-4648
Mailing address:
  • Phone: 212-288-2823
  • Fax: 212-208-4648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GERARD FUSARO
Title or Position: OWNER
Credential: DC
Phone: 212-288-2823