Healthcare Provider Details

I. General information

NPI: 1174610323
Provider Name (Legal Business Name): PATCHOGUE OPEN MRI, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 02/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 E MAIN ST SUITE 100
PATCHOGUE NY
11772-3121
US

IV. Provider business mailing address

475 E MAIN ST SUITE 100
PATCHOGUE NY
11772-3121
US

V. Phone/Fax

Practice location:
  • Phone: 631-447-2700
  • Fax:
Mailing address:
  • Phone: 631-447-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. ANTHONY DEGRADI
Title or Position: ADMINISTRATOR
Credential:
Phone: 631-447-2700