Basic Information
| Provider Information | |||||||||
| NPI: | 1376591818 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SILVER LAKE MEDICAL IMAGING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 150 | ||||||||
| Address2: | |||||||||
| City: | WARSAW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145690150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166922160 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WARSAW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145691025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857861262 | ||||||||
| FaxNumber: | 5857861251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 10/15/2007 | ||||||||
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| AuthorizedOfficialLastName: | OLIVERIO | ||||||||
| AuthorizedOfficialFirstName: | ROSEANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5857861262 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 02368101 | 05 | NY | MEDICAID |