Provider Demographics
NPI:1295008688
Name:ADVANCED DIAGNOSTIC IMAGING PLLC
Entity Type:Organization
Organization Name:ADVANCED DIAGNOSTIC IMAGING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SASAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AZAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-732-0621
Mailing Address - Street 1:4 TIDEWAY ST
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11024-1119
Mailing Address - Country:US
Mailing Address - Phone:516-732-0621
Mailing Address - Fax:631-366-0391
Practice Address - Street 1:90-20 ELMHURST AVENUE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7936
Practice Address - Country:US
Practice Address - Phone:516-732-0621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1941922085D0003X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic NeuroimagingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1937728Medicaid
NY1937728Medicaid