Healthcare Provider Details

I. General information

NPI: 1154982361
Provider Name (Legal Business Name): EAST RIVER DIAGNOSTIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 12/03/2022
Certification Date: 12/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 FRANKLIN PL
MASSAPEQUA NY
11758-7016
US

IV. Provider business mailing address

48 LEONARD DR
MASSAPEQUA NY
11758-7920
US

V. Phone/Fax

Practice location:
  • Phone: 516-410-3640
  • Fax:
Mailing address:
  • Phone: 212-288-2823
  • Fax: 212-208-4648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GERARD FUSARO
Title or Position: DIRECTOR
Credential: DC
Phone: 516-410-3640