Provider Demographics
NPI:1386834364
Name:K & G ULTRASOUND DIAGNOSTIC MEDICAL LABORATORY INC
Entity Type:Organization
Organization Name:K & G ULTRASOUND DIAGNOSTIC MEDICAL LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT GROUP ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ZINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUBICH
Authorized Official - Suffix:
Authorized Official - Credentials:CDMS CUT CDCS
Authorized Official - Phone:718-421-6363
Mailing Address - Street 1:1452 FLATBUSH AVENUE
Mailing Address - Street 2:K & G ULTRASOUND DIAGNOSTIC MED LAB
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210
Mailing Address - Country:US
Mailing Address - Phone:718-421-6363
Mailing Address - Fax:941-429-0260
Practice Address - Street 1:1452 FLATBUSH AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210
Practice Address - Country:US
Practice Address - Phone:718-421-6363
Practice Address - Fax:718-421-6363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY84548OtherGHI
NY00718176Medicaid
NY97907OtherBC
NYW93751OtherMEDICARE GLOBAL
B79198Medicare UPIN