Basic Information
| Provider Information | |||||||||
| NPI: | 1649668930 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIUM DIAGNOSTIC IMAGING PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1608 59TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112042129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188727585 | ||||||||
| FaxNumber: | 7189754337 | ||||||||
| Practice Location | |||||||||
| Address1: | 1608 59TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112042129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188727585 | ||||||||
| FaxNumber: | 7188727591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2015 | ||||||||
| LastUpdateDate: | 01/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | GREENFIELD | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWENER | ||||||||
| AuthorizedOfficialTelephone: | 7188727585 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 176673 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.