MEDICARE: MOSHOLU 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	2085B0100X	Body Imaging Physician	1252131	NY
2	2085U0001X	Diagnostic Ultrasound Physician	1252131	NY
3	2085N0904X	Nuclear Radiology Physician	1252131	NY

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	:	1710996509
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOSHOLU PARK RADIOLOGY PC

Provider Business Mailing Address
First Line	:	MOSHOLU PARK RADIOLOGY PC
Second Line	:	3130 GRAND CONCOURSE STE 1P
City	:	BRONX
State	:	NY
Zip	:	10458
Country	:	US
Telephone Number	:	718-933-6969
Fax Number	:	718-933-6970

Provider Business Practice Location Address
First Line	:	MOSHOLU PARK RADIOLOGY PC
Second Line	:	3130 GRAND CONCOURSE STE 1P
City	:	BRONX
State	:	NY
Zip	:	10458
Country	:	US
Telephone Number	:	718-933-6969
Fax Number	:	718-933-6970

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ANDRESITO B PACIS
Credential	:	MD
Telephone Number	:	718-933-6969

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	09/11/2025

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