=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982694543
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH NASSAU RADIOLOGY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2005
-----------------------------------------------------
Last Update Date | 12/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 HEALTHY WAY ATTN: RADIOLOGY
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11572-1551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-632-4656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5768
-----------------------------------------------------
City | HICKSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11802-5768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-632-4656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | STEPHEN LASTIG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 516-632-4656
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------