Basic Information
Provider Information
NPI: 1174537948
EntityType: 2
ReplacementNPI:  
OrganizationName: INTEGRATED DIAGNOSTIC IMAGING AND CARDIOLOGY OF STATEN ISLAND, PC
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Mailing Information
Address1: 831 LITTLE BRITAIN RD
Address2: # 200
City: NEW WINDSOR
State: NY
PostalCode: 125535518
CountryCode: US
TelephoneNumber: 8454461100
FaxNumber: 8455624902
Practice Location
Address1: 831 LITTLE BRITAIN RD
Address2: # 200
City: NEW WINDSOR
State: NY
PostalCode: 125535518
CountryCode: US
TelephoneNumber: 8454461100
FaxNumber: 8455624902
Other Information
ProviderEnumerationDate: 07/28/2006
LastUpdateDate: 06/14/2016
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: STROBECK
AuthorizedOfficialFirstName: JOHN
AuthorizedOfficialMiddleName: E.
AuthorizedOfficialTitleorPosition: DIRECTOR
AuthorizedOfficialTelephone: 2018887877
IsSoleProprietor:  
IsOrganizationSubpart: N
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AuthorizedOfficialCredential: M.D.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RC0000X1306831NYN193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
2085R0202X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology

ID Information
IDTypeStateIssuerDescription
0274365305NY MEDICAID
130683101NYNY MEDICAL LICENSEOTHER


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