Provider Demographics
NPI:1265635015
Name:INNOVATIVE MR IMAGING, PC
Entity Type:Organization
Organization Name:INNOVATIVE MR IMAGING, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-369-8272
Mailing Address - Street 1:PO BOX 30271
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-0271
Mailing Address - Country:US
Mailing Address - Phone:718-815-2002
Mailing Address - Fax:718-815-3003
Practice Address - Street 1:5000 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1602
Practice Address - Country:US
Practice Address - Phone:718-815-2002
Practice Address - Fax:718-815-3003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty