Provider Demographics
NPI:1093949893
Name:SUPREME MEDICAL DIAGNOSTIC,P.C.
Entity Type:Organization
Organization Name:SUPREME MEDICAL DIAGNOSTIC,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ILYA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:BURSHTEYN
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:212-288-3474
Mailing Address - Street 1:215 E 68TH ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-5718
Mailing Address - Country:US
Mailing Address - Phone:212-288-2553
Mailing Address - Fax:
Practice Address - Street 1:215 E 68TH ST
Practice Address - Street 2:SUITE 8
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-5718
Practice Address - Country:US
Practice Address - Phone:212-288-2553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-07
Last Update Date:2009-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty