Provider Demographics
NPI:1144946534
Name:NORTHWELL DIAGNOSTIC GROUP LLC
Entity type:Organization
Organization Name:NORTHWELL DIAGNOSTIC GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FUSARO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:212-288-2823
Mailing Address - Street 1:801 NORTHPOINT PKWY STE 313
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-1973
Mailing Address - Country:US
Mailing Address - Phone:212-288-2823
Mailing Address - Fax:212-208-4648
Practice Address - Street 1:801 NORTHPOINT PKWY STE P4
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-1973
Practice Address - Country:US
Practice Address - Phone:212-288-2823
Practice Address - Fax:212-208-4648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-17
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty