1073590113 NPI number — PARKLAND DIAGNOSTIC IMAGING, PLLC

Table of content: (NPI 1073590113)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073590113 NPI number — PARKLAND DIAGNOSTIC IMAGING, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARKLAND DIAGNOSTIC IMAGING, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073590113
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 18005
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAUPPAUGE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11788-8805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-517-8000
Provider Business Mailing Address Fax Number:
631-893-1923

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3055 SOUTHWESTERN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORCHARD PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14127-1231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-677-6736
Provider Business Practice Location Address Fax Number:
716-677-6144
Provider Enumeration Date:
12/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LIEBERMAN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR/RADIOLOGIST
Authorized Official Telephone Number:
631-517-8006

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02677205 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: DG7385 . This is a "RR MEDICARE PIN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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