MEDICARE: MARINE PARK RADIOLOGY PC

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	2085R0202X	Diagnostic Radiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639217425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARINE PARK RADIOLOGY PC

Provider Business Mailing Address
First Line	:	PO BOX 13245
Second Line	:
City	:	HAUPPAUGE
State	:	NY
Zip	:	11788-0840
Country	:	US
Telephone Number	:	631-952-5701
Fax Number	:	631-952-5740

Provider Business Practice Location Address
First Line	:	450 AVENUE P
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11223-1902
Country	:	US
Telephone Number	:	718-375-6000
Fax Number	:	718-375-6576

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	ALFREDO C. ROQUE
Credential	:	MD
Telephone Number	:	718-375-6000

Provider Enumeration Date	:	02/02/2007
Last Update Date	:	05/06/2008

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