Provider Demographics
NPI:1003942855
Name:MOBILE DIAGNOSTIC TESTING SERVICES INC
Entity Type:Organization
Organization Name:MOBILE DIAGNOSTIC TESTING SERVICES INC
Other - Org Name:HEALTHTRAC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCDONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-686-7110
Mailing Address - Street 1:4950 GENESEE ST
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14225-5550
Mailing Address - Country:US
Mailing Address - Phone:716-686-7100
Mailing Address - Fax:716-614-3282
Practice Address - Street 1:4950 GENESEE ST
Practice Address - Street 2:SUITE 180
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14225-5550
Practice Address - Country:US
Practice Address - Phone:716-686-7100
Practice Address - Fax:716-614-3282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7602181OtherIHA
NY000510159003OtherBC BS WNY
NY00020000502OtherUNIVERA
NY0073926OtherGOVT INS
NYP00105453Medicare PIN
NY00020000502OtherUNIVERA