Basic Information
Provider Information
NPI: 1275545022
EntityType: 2
ReplacementNPI:  
OrganizationName: PORT RADIOLOGY SERVICES PC
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Mailing Information
Address1: 270 PARK AVE
Address2:  
City: HUNTINGTON
State: NY
PostalCode: 117432787
CountryCode: US
TelephoneNumber: 6313512000
FaxNumber:  
Practice Location
Address1: 270 PARK AVE
Address2:  
City: HUNTINGTON
State: NY
PostalCode: 117432787
CountryCode: US
TelephoneNumber: 6313512000
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/12/2006
LastUpdateDate: 08/22/2020
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: GLENN
AuthorizedOfficialFirstName: EDWARD
AuthorizedOfficialMiddleName: J
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 6313512000
IsSoleProprietor:  
IsOrganizationSubpart: N
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AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2085R0202X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology

ID Information
IDTypeStateIssuerDescription
0167565805NY MEDICAID


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