Basic Information
| Provider Information | |||||||||
| NPI: | 1710937727 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKES RADIOLOGY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 ERIE AVE | ||||||||
| Address2: | RADIOLOGY | ||||||||
| City: | HORNELL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148431909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6073248255 | ||||||||
| FaxNumber: | 6073248774 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 CANISTEO ST | ||||||||
| Address2: | RADIOLOGY | ||||||||
| City: | HORNELL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148432104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6073248255 | ||||||||
| FaxNumber: | 6073248774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 02/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | NETANYAHU | ||||||||
| AuthorizedOfficialFirstName: | IDDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6073248255 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 167192 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 02412119 | 05 | NY | MEDICAID | 000914685002 | 01 | NY | HEALTHNOW | OTHER | G0187663370 | 01 | NY | BCBS OF CNY | OTHER |