Provider Demographics
NPI:1174610323
Name:PATCHOGUE OPEN MRI, PC
Entity type:Organization
Organization Name:PATCHOGUE OPEN MRI, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGRADI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-447-2700
Mailing Address - Street 1:475 E MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3121
Mailing Address - Country:US
Mailing Address - Phone:631-447-2700
Mailing Address - Fax:
Practice Address - Street 1:475 E MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3121
Practice Address - Country:US
Practice Address - Phone:631-447-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA0W351210Medicare PIN