Basic Information
| Provider Information | |||||||||
| NPI: | 1629108063 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHTOWNS RADIOLOGY ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3040 AMSDELL RD | ||||||||
| Address2: | |||||||||
| City: | HAMBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140755835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166499000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3040 AMSDELL RD | ||||||||
| Address2: | |||||||||
| City: | HAMBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140755835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166499000 | ||||||||
| FaxNumber: | 7166499005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 01/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | JOYCE | ||||||||
| AuthorizedOfficialFirstName: | GERALD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7166499000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | CE8352 | 01 | NY | RAILROAD MEDICARE | OTHER | 00026681804 | 01 | NY | UNIVERA | OTHER | 040426000332 | 01 | NY | FIDELIS | OTHER | 03069821 | 05 | NY | MEDICAID | 000508387008 | 01 | NY | BCBS WESTERN NY | OTHER | 146156FF | 01 | PREFERRED CARE | OTHER |