Basic Information
Provider Information | |||||||||
NPI: | 1174537948 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INTEGRATED DIAGNOSTIC IMAGING AND CARDIOLOGY OF STATEN ISLAND, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STROBECK | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | E. | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2018887877 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 1306831 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 2085R0202X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 02743653 | 05 | NY |   | MEDICAID | 1306831 | 01 | NY | NY MEDICAL LICENSE | OTHER |