MEDICARE: LAKES RADIOLOGY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center

General Provider Information

NPI Number	:	1265409635
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKES RADIOLOGY PLLC

Provider Business Mailing Address
First Line	:	PO BOX 2004
Second Line	:
City	:	EAST SYRACUSE
State	:	NY
Zip	:	13057-4504
Country	:	US
Telephone Number	:	315-362-5285
Fax Number	:	315-445-2936

Provider Business Practice Location Address
First Line	:	8395 OSWEGO RD
Second Line	:
City	:	BALDWINSVILLE
State	:	NY
Zip	:	13027-6801
Country	:	US
Telephone Number	:	315-857-0094
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	IDDO NETANYAHU
Credential	:	MD
Telephone Number	:	315-857-0094

Provider Enumeration Date	:	03/03/2006
Last Update Date	:	09/16/2010

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