Basic Information
| Provider Information | |||||||||
| NPI: | 1467794354 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RENAISSANCE MEDICAL IMAGING PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5106 VERNON BLVD | ||||||||
| Address2: | STE 204 | ||||||||
| City: | LONG ISLAND CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6467132955 | ||||||||
| FaxNumber: | 8778887955 | ||||||||
| Practice Location | |||||||||
| Address1: | 5106 VERNON BLVD | ||||||||
| Address2: | STE 204 | ||||||||
| City: | LONG ISLAND CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6467132955 | ||||||||
| FaxNumber: | 8778887955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2013 | ||||||||
| LastUpdateDate: | 05/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | DENISE | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6467132955 | ||||||||
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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 | 00922725 | 05 | NY | MEDICAID |