Provider Demographics
NPI:1174825343
Name:PROFESSIONAL DIAGNOSTIC SPECIALISTS,
Entity Type:Organization
Organization Name:PROFESSIONAL DIAGNOSTIC SPECIALISTS,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIVEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-896-6443
Mailing Address - Street 1:4 WINTERBERRY CT
Mailing Address - Street 2:
Mailing Address - City:MARLBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:07746
Mailing Address - Country:US
Mailing Address - Phone:718-986-6443
Mailing Address - Fax:732-837-4514
Practice Address - Street 1:345 US HIGHWAY 9
Practice Address - Street 2:SUITE 8
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-3239
Practice Address - Country:US
Practice Address - Phone:732-845-2200
Practice Address - Fax:732-837-4514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-22
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty