Healthcare Provider Details

I. General information

NPI: 1811903578
Provider Name (Legal Business Name): SHORE ROAD RADIOLOGY ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 55TH ST
BROOKLYN NY
11220-2559
US

IV. Provider business mailing address

5800 3RD AVE LUTHERAN MEDICAL CENTER-MANAGED CARE DEPARTMENT
BROOKLYN NY
11220-3702
US

V. Phone/Fax

Practice location:
  • Phone: 718-630-7477
  • Fax: 718-630-7437
Mailing address:
  • Phone: 718-630-7477
  • Fax: 718-630-7437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number16820
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number16820
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number16820
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number16820
License Number StateNY

VIII. Authorized Official

Name: MR. GARY DELLACERRA
Title or Position: VP MANAGED CARE & REVENUE COMPLIANC
Credential: V.P.
Phone: 718-630-7103