Provider Demographics
NPI:1235102450
Name:NEW YORK DIAGNOSTIC CENTER INC.
Entity Type:Organization
Organization Name:NEW YORK DIAGNOSTIC CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEBALCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-288-1113
Mailing Address - Street 1:PO BOX 1069
Mailing Address - Street 2:
Mailing Address - City:WESTHAMPTON BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11978-7069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:266 W 37TH ST
Practice Address - Street 2:12TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-6609
Practice Address - Country:US
Practice Address - Phone:212-947-8522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7002138R261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center